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Specialties > Elderly - Confusion > Flashcards

Elderly - Confusion Flashcards

1
Q

Why is it important to asses cognition?

A
  • 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!
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2
Q

How do you diagnose cognitive impairment?

A

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
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3
Q

What are the 2 most common causes of cognitive impairment?

A

Delirium and Dementia

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4
Q

What is delirium?

SSx of delirium?

A

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
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5
Q

What is the cause of delirium?

A

Unknown.

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6
Q

What precipitates delirium?

A
  • 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.
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7
Q

Why do we care about delirium?

A
  • 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
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8
Q

How is delirium diagnosed?

A

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

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9
Q

What do you do if you find delirium?

A
  • Treat the causative problem.
    • Full history and examination
    • TIME bundle
  • Explanation of the diagnosis is vital.
  • Pharmacological measures can help.
  • So can non-pharma.
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10
Q

What are the non-pharmacological treatments of delirium?

A
  • 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.
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11
Q

What are the pharmacological treatments of delirium?

A
  • 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.
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12
Q

What is dementia?

A

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
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13
Q

Outline Alzheimers dementia.

A
  • Slow, insidious onset
  • Loss of recent memory first
  • Progressive functional decline

Risk Factors

  • Age!
  • Vascular risk factors
  • Genetics
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14
Q

Outline Vascular Dementia

A
  • 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

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15
Q

Outline Lewy Body Dementia

A
  • May have parkinsonism
  • Often very fluctuant
  • Hallucinations common
  • Falls common
  • Probably underdiagnosed
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16
Q

Outline Frontotemporal Dementia

A
  • 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.

17
Q

How is dementia diagnosed?

A

Cognitive Screening Tools

  • Mini-mental State Exam - focus on memory, rather than executive function
  • MOCA - again limits in the neuro-cognitive domains explored.
18
Q

What are the problems with the mental state tests?

A
  • 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
19
Q

What is the non pharmacological management of dementia?

A
  • Support for person and carers
  • Cognitive stimulation
  • Exercise
  • Environmental design
  • Avoiding changes in environment/social support etc
  • Advanced care planning
20
Q

What is the pharmacological management of dementia?

A
  • Cholinesterase inhibitors
    • Mainly used in Alzheimers
      • Galantamine licensed in mixed dementia
      • Rivastigmine in Dementia with Lewy Bodies
  • 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
21
Q

What are some of the reversible dementia causes than must be remmebered?

A
  • Hypothyroidism
  • Intracerebral bleeds/tumours
  • B12 deficiency
  • Hypercalcaemia
  • Normal pressure hydrocephalus
  • ALWAYS REMEMBER DEPRESSION
22
Q

What is the link between capacity and delirium/dementia?

A

Person specific and Decision specific

In delirium capacity can fluctuate.

Important to remember if Power of Attorney is done.

23
Q

There are cases on lecture, so go and look.

A

sweet

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