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Older Persons Medicine > Dimentia & Delirium > Flashcards

Dimentia & Delirium Flashcards

1
Q

What are the causes of confusion in elderly?

*remember 4D 1M

A
  • Deliruim
  • Depression
  • Dementia
  • Drugs
  • Metabolism
    • hypothyroidism
    • hypercalcaemia
    • vit B12 def
    • hydrocephlus
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2
Q

What is Dementia?

A
  • Decline in higher cortical function
  • Imparied memory, intellect, personality
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3
Q

What are the two types of dementia based on onset?

A
  • Early onset - <65
  • Late onset - >65
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4
Q

What are the 5 types of dementia?

*remember FLAVPM

A
  • Frontal lobe dementia (2nd common cause of early onset)
  • Lewi Body dementia
  • Alzheimer’s dementia (1st common)
  • Vascular dementia (2nd common)
  • Parkinson’s disease c demnetia
  • Mixed dementia (A+V)
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5
Q

What are the macroscopic changes in AD?

A
  • global atrophy
  • sulcus widening
  • enlarged 3rd & 4th interventricular space
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6
Q

What are the microscopic features of AD?

A
  • senile amyloid plaques (around neurones)
  • neurofibrillary tau tangles (inside neurones)
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7
Q

What causes the deposition of amyloid?

A
  1. mutated Amyloid Precursor Protein (APP) and B-secretase enzyme
  2. Incomplete breakdown of APP
  3. amyloid deposition occur
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8
Q

What are the causes of AD?

A
  • Early onset
    • B-APP
    • Presenilin 1
    • Presenilin 2
  • Late onset
    • Apolipoprotein E gene
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9
Q

What are the Sx for AD?

A
  • decline memory
  • decline spatial navigation
  • decline executive function
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10
Q

Which genetic disorder is at high risk of developing AD and why?

A
  • Downs Syndrome
  • APP gene located on chromosome 21
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11
Q

What cognitive assessments can you perform for dementia pt?

A
  • Mini Mental State Examination (MMS)
  • Abbreviated Mental Test (AMT)
  • 6 item cognitive impairment test (6-CIT)
  • General Practitioner Assessment of Cognition (GPCOG)
  • 7 Minute Screen (7MS)
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12
Q

What are the reversible causes of dementia?

A
  • alcohol dependence
  • hypothyroidism
  • vit b12 def
  • syphilis
  • normal pressure hydrocephalus (NPH)
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13
Q

What are the 3 phases of AD?

A
  1. Asymptomatic phase
    • changes at tissue level
    • no sx
  2. Predementia phase
    • memory starts to decline
    • daily functioning not affected
  3. Dementia phase
    • significant memory loss
    • daily functioning affected
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14
Q

What Ix can you order for AD?

A
  • Bedside
    • MCA/MMS
  • Imaging - show cortical atrophy
    • CT
    • MRI
    • Fluorodeoxyglucose (FDG) PET Scan
  • Special test
    • Brain biopsy (definitive dx) *only performed during autopsy
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15
Q
A
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16
Q

How would you Mx AD?

A
  • AChE inh
    • Donepezil (first line)
    • Galantamine
    • Rivastigmine
  • NMDA RA - Glutamate inh
    • Memantine (second line)
  • SSRI
    • Doxepin
    • Amitryptilin
  • Risperidone
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17
Q

What are the side effects of AChE inh?

A
  • Diarrhoea
  • Vomiting
  • syncope
  • bradycardia
  • heart block
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18
Q

Glutamate is an excitatory neurotransmitter for learning and memory. Why give Memantine for AD?

A
  1. in AD - too much glutamate
  2. overexcitation of cells
  3. high Ca in cells
  4. cell death
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19
Q

What is the Px of Lewi body dementia?

A
  1. Misfolding of alpha-synuclein protein
  2. Aggregation - form lewi body in substantia nigra, temporal lobe, frontal lobe, cingulate gyrus
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20
Q

What are the Sx for LBD?

*remember haLEWYcinations

A
  • visual/auditory hallucinations
  • fluctuating, episodic deficits of attention and alertness
  • parkinsonism (TRAP)
    • tremor
    • rigidity
    • Akinesia
    • postural instability
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21
Q

How would you Mx LBD?

A
  • same as AD
  • avoid antipsychotics for hallucinations - can worsen parkinsonism
  • LEVADOPA - but weigh with risk of developing delirium
22
Q
A
23
Q

What are the RF for vascular dementia?

A
  • HTN
  • DM
  • coronary artery disease
  • smoking
24
Q

What type of stroke is vascular dementia associated with?

A

Multi-infarct dementia

25
Q

Lacunar stroke is seen in VD. What arteries are affected?

A
  • lenticulostriate arteries - branch of MMA
26
Q

What pattern of cognitive deterioration is demonstrated in VD?

A
  • Stepwise deterioration
  • AD is gradual decline
27
Q

What are the Sx for VD?

A
  • urinary incontinence
  • cranial nerve palsy
  • focal neurological deficit
  • late -onset memory loss
28
Q

How would you Mx VD?

A
  • Lifestyle changes - aim to prevent another stroke from happening
    • control HTN/DM/Cholesterol
  • Pharmacology
    • *same as AD
29
Q

What is the Px of frontotemporal lobe dementia?

A
  1. Atrophy of fontal and temporal lobes
30
Q

What are the Sx for FTD?

A

Present <65

  • Early onset of personality & behavioral changes
  • aphasia
31
Q

What is FTD also known as?

A

Pick’s disease

32
Q
A
33
Q

What is the difference between Parkinson’s disease dementia and Lewi body dementia?

A
  • Sequence of events
  • PDD
    • TRAP and then dementia
  • LBD
    • dementia and then TRAP
34
Q

What is Delirium?

A
  • Acute, sudden onset confusion with fluctuating course
  • Develops over 1-2 days
35
Q

What are the causes of delirium?

*remember DELIRIUM

A
  • Drug toxicity
    • withdrawal: alcohol, benzos, cocaine, coffee
    • (see other flash cards)
  • Endocrine
    • hyper/hypo thyroidism
    • addisons
    • cushing’s
  • Liver failure - NH3 build up in blood
  • Intracranial
    • stroke
    • haemorrhage
    • abcess
    • epilepsy
  • Renal failure
  • Infections
    • pneumonia, UTI, sepsis, meningitis
  • Urinary retention
  • Metabolic
    • hypoxia
    • electrolyte imbalance
36
Q

What drug toxicity can cause delirium?

A
  • anticholinergics
  • anti histamines
  • beta-blockers
  • corticosteroids
  • calcineurin inh.
  • dopamine agonist
  • levodopa
  • monoamine oxidase inh
  • opiates
  • tricyclic antidepressant
37
Q

What are the Sx of Delirium?

A
  • hyperactivity and agitation or hypoactivity and drowsiness
  • inattention/difficulty focusing
  • +/- disorientation
  • illusions, delusion, hallucination
  • sleep disturbances
  • hypersensitivity to light and sound
38
Q
A
39
Q

What are the features of delirium sx?

A
  • hours to days
  • fluctuates in a day
  • worsens at niight
40
Q

How would you diagnose delirium?

A
  • Clinically
    • Acute illness + confusion (x explained by another neuropsychiatric syndrome)
  • Bedside
    • DSM V
    • Confusion Assessment Method (CAM)
41
Q

What are the RF for delirium?

A
  • 65 or older
  • sensory impairment
  • cognitive impairement
  • surgery
  • current hip fracture
  • severe infections
42
Q

What Ix would you order for delirium?

A
  • Bedside
    • routine bloods, blood culture, inflammatory markers, liver function test, troponin, ABG
    • finger stick blood glucose
    • urine dip
    • oxygen sats, BP, ECG
    • check polypharmacy
  • Ix
    • CXR
    • CT head - for suspected stroke
  • Special
    • lumbar punture
43
Q

What are the differentials for delirium?

A

Common

  • dementia
  • stroke/TIA
  • MI
  • pain

Uncommon

  • head injury
  • adrenal crisis
  • thyrotoxicosis
44
Q

What mental test will you perform to assess delirium?

A
  • Confusion Assessment Method (CAM)
  • 4AT
45
Q

How would you Mx delirium?

A
  • initial mx
    • tx underlying cause - best way to reverse delirium
    • ensure effective communication and reorientation
    • consider involving family, social care
  • if pt is disstressed and at risk to themselves or others
    • use verbal and non verbal techniques to de-escalate situation
    • haloperidol
    • antipsychotic
    • physical restrain (last resort)
46
Q

What is the CAM?

A

To have a positive result the patient must have:

  • Acute onset and fluctuating course; and
  • Inattention (eg, 20-1 test with reduced capacity to shift attention or keep attention focused); and either
  • Disorganised thinking (disorganised or incoherent speech) or
  • Changed level of consciousness (usually the patient is lethargic or is in a state of stupor).
47
Q

What is delirium associated with?

A
  • increase mortality
  • prolonged hospital admission
  • higher complication rates
  • institutionalisation
  • high risk of developing dementia
48
Q

What are the types of delirium?

A
  • Hyperactive (agitated & confuse)
  • Hypoactive (withdrawn and drowsy)
  • Mixed
49
Q

What does the 4AT briefly comprise of?

A
  • Alertness
  • Abbreviated Mental Test 4 (AMT4)
    • age, dob, name of hospital, current year
  • Attention
    • list months of year backwards
  • Acute change or fluctuating course
50
Q

What are examples of potentially treatable dementia?

A
  • Substance misuse
  • Hypothyroidism
  • Space-occupying intracranial lesions
  • Normal pressure hydrocephalus
  • Syphilis
  • Vitamin B12 deficiency
  • Folate deficiency
  • Pellagra

Older Persons Medicine (3 decks)

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