Elderly Medicine

Question 1

What are the causes of Delirium

Answer 1

metabolic causes: hypercalcaemia, hypoglycaemia, hyponatraemia, dehydration

infections: UTIs, pneumonia

trauma: hip fractures

drugs

change in environment

constipation

urinary retention

Question 2

What is the main distinguishing factor between dementia and delirium

Answer 2

Acute alteration in the level of awareness and attention (decreased consciousness)

Question 3

What investigations would you conduct to look for the underlying cause of delirium?

Answer 3

Urinalysis (UTI)
Chest x-ray (Infection)
CRP/WCC
Serum glucose (hypoglycaemia)
Bladder scan (urinary retention)
Electrolytes

Question 4

What tests are involved with a confusion screen?

Answer 4

TFTs (Hypothyroidism)
B12
Folate
Glucose (Hypoglycaemia)
Bone Profile (Hypercalcaemia)

Question 5

What are the Cognitive Impairment Screening Tests?

Answer 5

AMTS or MMSE or MoCA

Question 6

What AMTS score suggests delirium or dementia

Answer 6

AMTS (6 or less suggests delirium or dementia)

Question 7

What is the management for Delirium

Answer 7

Treat Underlying Condition (eg. acute urinary retention - Catheterize)

Patient Comfort & Symptom Control → fever control, pain management, maintaining adequate hydration

Reducing Confusion → reorient patient to time, place and person a few times a day

Question 8

What is the pathophysiology of Alzhiemer’s

Answer 8

Degeneration of the cerebral cortex, with cortical atrophy and reduction in acetylcholine production. Build up of APP (due to beta and gamma secretase).

Categorised as Mild/Moderate/Severe

Question 9

What is the pathophysiology of Vascular Dementia

Answer 9

Brain damage due to several incidents of cerebrovascular disease (e.g. strokes/TIAs)

Question 10

What is the pathophysiology of Lewy Body Dementia

Answer 10

Deposition of abnormal proteins (Lewy bodies) within the brain stem and neocortex

Question 11

What is the pathophysiology of Frontotemporal Dementia

Answer 11

Specific degeneration of the frontal and temporal lobes. Thought to be caused by pick bodies.

Question 12

What is the most to least common type of Dementia

Answer 12

Alzheimer’s > Vascular > Lewy Body > Frontotemporal

Question 13

What are the clinical features of Alzheimer’s Disease

Answer 13

Alzheimer’s Disease → slowly progressive, episodic impairment of memory

Question 14

What are the clinical features of Vascular Dementia

Answer 14

abrupt cognitive decline and stepwise deterioration

Question 15

What are the clinical features of Lewy Body Dementia

Answer 15

Steady decline, fluctuating levels of consciousness, visual hallucinations and parkinsonian motor disorders

Question 16

What are the clinical features of Frontotemporal Dementia

Answer 16

Early changes in personality (eg. Impulsivity, aggressiveness). Often has a family history. Starts slightly earlier than other dementias (50-60).

Question 17

What cognitive examination do you use to assess for Dementia and what score would suggest a positive diagnosis

Answer 17

Mini-Mental State Examination

(MMSE, patient who scores 24 points or less is generally considered to have dementia)
- 24-30 (no cognitive impairment), 18-23 (mild cognitive impairment), 0-17 (severe cognitive impairment)

Question 18

What is the management plan for Alzheimer’s

Answer 18

• 1st Line (mild-moderate Alzheimer’s) → acetylcholinesterase inhibitors (donepezil, rivastigmine - if hallucinations one of main symptoms, galantamine)
  • Prolonged QT = contraindication for acetylcholinesterase inhibitors
• 2nd Line (or for severe Alzheimer’s) → memantine (NMDA receptor antagonist, leading to decreased glutamate induced excitotoxicity)