Elderly - Confusion Flashcards
Why is it important to asses cognition?
- May be relevant to current medical problems
- Associated with increased risk death/increased LOS/discharge to care home
- May need to alter communication/information given/involvement of family members
- Help you decide regarding capacity
- May alter appropriateness of tests/investigations/certain treatments
- May be able to improve it!
How do you diagnose cognitive impairment?
History is the key, including a collateral history. To find out:
- Onset
- –When
- –How rapid
- Course
- –Fluctuating
- –Progressive decline
- Associated features
- –Other illness
- –Functional loss – e.g. reduced mobility, reduced self-care, new incontinence
What are the 2 most common causes of cognitive impairment?
Delirium and Dementia
What is delirium?
SSx of delirium?
Acute decline in cognitive function.
Delirium effects the extremes of age. But is more likely in the frail.
- Disturbed consciousness
- Hypoactive/hyperactive/mixed
- Change in cognition
- Memory/perceptual/language/illusions/hallucinations
- Acute onset and fluctuant
Other common features
- Disturbance of sleep wake cycle
- Disturbed psychomotor behaviour
- Emotional disturbance
What is the cause of delirium?
Unknown.
What precipitates delirium?
- Infection (but not always a UTI!)
- Dehydration
- Biochemical disturbance
- Pain - opiate painkillers can make delirium worse.
- Drugs - either directly or indirectly (cause AKI for example)
- Constipation/Urinary retention
- Hypoxia
- Alcohol/drug withdrawal
- Sleep disturbance
- Brain injury
- Stroke/tumour/bleed etc
- Changes in environment - respite care, new carer etc.
- Sometimes cause is unknown, and maybe multiple triggers.
Why do we care about delirium?
- 20-30% of all in-patients will have it at some point
- Up to 50% post surgery
- Up to 85% in last few weeks of life
- Commonest complication of hospitalisation
- Massive morbidity and mortality
- Increased risk of death
- Longer length of stay
- Increased rates institutionalisation
- Persistent functional decline
How is delirium diagnosed?
4AT - Delirium Screening Tool
Everyone over the age of 65.
Consists of simple questions, helps to ascertain if there is delirium.
Also looks at attention - inattention is a big issue
What do you do if you find delirium?
- Treat the causative problem.
- Full history and examination
- TIME bundle
- Explanation of the diagnosis is vital.
- Pharmacological measures can help.
- So can non-pharma.
What are the non-pharmacological treatments of delirium?
- Re-orientate and reassure agitated patients.
- Use families and carers.
- Encourage early mobility and self care
- Correction of sensory impairment
- Normalise sleep-wake cycle
- Ensure continuity of care
- Avoid frequent ward or room transfers
- Avoid urinary catheterisation/venflons - reasons for catheter must be more than incontinence.
What are the pharmacological treatments of delirium?
- Remember DRUGS ARE BAD (mostly….)
- STOP BAD DRUGS
- Anticholinergics
- Sedatives
- Drug treatment of delirium usually not necessary
- No evidence it improves outcomes
- Only if danger to themselves or others or distress which cannot be settled in any other way
- Start low and go slow
- 12.5mg quetiapine orally - iv etc can be even more distressing.
- Only if danger to themselves or others or distress which cannot be settled in any other way
What is dementia?
Acquired decline in memory and other cognitive functions in an alert person sufficiently severe to cause functional impairment and present for more than 6 months
- ie forgetting to take tablets
- Unable to use phone
- Difficulty washing/dressing
Common types:
- Alzheimers
- Vascular dementia
- Mixed Alzeimers/Vascular
- Dementia with Lewy Bodies
- ‘Reversible’ causes
Outline Alzheimers dementia.
- Slow, insidious onset
- Loss of recent memory first
- Progressive functional decline
Risk Factors
- Age!
- Vascular risk factors
- Genetics
Outline Vascular Dementia
- Classically step-wise deterioration
- Executive dysfunction may predominate rather than memory impairment
- Associated with gait problems often.
- Often have known vascular risk factors
–type II DM, AF, IHD, PVD
Outline Lewy Body Dementia
- May have parkinsonism
- Often very fluctuant
- Hallucinations common
- Falls common
- Probably underdiagnosed
Outline Frontotemporal Dementia
- Onset often at earlier age
- Early symptoms different from other types of dementia
- Behavioural change
- Language difficulties
- Memory early on often not affected
Usually lack insight into difficulties.
How is dementia diagnosed?
Cognitive Screening Tools
- Mini-mental State Exam - focus on memory, rather than executive function
- MOCA - again limits in the neuro-cognitive domains explored.
What are the problems with the mental state tests?
- Can be culturally/generationally/intellectually specific
- Can be falsely reassuring
- Use as screening and monitoring tools, not as only means of diagnosis
- REMEMBER HISTORY IS KEY
- What matters to the patient is often whether they can function independently at home, not how much they score on MMSE
What is the non pharmacological management of dementia?
- Support for person and carers
- Cognitive stimulation
- Exercise
- Environmental design
- Avoiding changes in environment/social support etc
- Advanced care planning
What is the pharmacological management of dementia?
- Cholinesterase inhibitors
- Mainly used in Alzheimers
- Galantamine licensed in mixed dementia
- Rivastigmine in Dementia with Lewy Bodies
- Mainly used in Alzheimers
- Not a miracle cure
- Max 2-3 point improvement in MMSE
- May delay move to care home
- Anti-psychotics
- As with delirium avoid if possible
- Increased risk cardiovascular death
- Start low and go slow
What are some of the reversible dementia causes than must be remmebered?
- Hypothyroidism
- Intracerebral bleeds/tumours
- B12 deficiency
- Hypercalcaemia
- Normal pressure hydrocephalus
- ALWAYS REMEMBER DEPRESSION
What is the link between capacity and delirium/dementia?
Person specific and Decision specific
In delirium capacity can fluctuate.
Important to remember if Power of Attorney is done.
There are cases on lecture, so go and look.
sweet
