Geriatics: Confusion Flashcards
What should we think about when we refer to someone as being confused?
Their cognitive ability
What are the 6 neurocognitive domains?
- Complex attention
- Perceptual-motor function
- Language function
- Executive function
- Learning/memory
- Social cognition
Why is assessing cognition important?
- 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!
What is key in diagnosing cognitive impairment?
History
What is important to establish when taking a history in cognitive impairment?
Onset
- When
- How rapid
Course
- Fluctuating?
- Progressive decline
Associated features
- Other illness
- Functional loss
What are the key features of delirium?
Disturbed consciousness
-Hypoactive/hyperactive/mixed
Change in cognition
-Memory/perceptual/language/illusions/hallucinations
Acute onset and fluctuant
What features commonly occur in delirium
- Disturbance of sleep wake cycle
- Disturbed psychomotor behaviour
- Emotional disturbance
What precipitates delirium?
- Infection (but not always a UTI!)
- Dehydration
- Biochemical disturbance
- Pain
- Drugs
- Constipation/Urinary retention
- Hypoxia
- Alcohol/drug withdrawal
- Sleep disturbance
- Brain injury
- Change in environment
Why is it important to know about delirium?
- Very common particularly in elderly
- Commonest complication of hospitalisation
- Massive morbidity and mortality
How is delirium diagnosed?
4AT score
What should you de when you diagnose delirium?
- Explain the diagnosis
- Treat the cause (establish from history and exam, TIME bundle)
How should a patient with delirium be managed ?
- Re-orientate and reassure agitated patients (USE FAMILIES/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
How should delirium be managed pharmacologically?
- Drug treatment of delirium is usually not necessary
- STOP BAD DRUGS (including anticholinergics and sedatives)
- Sedatives should only be used if the patient is a danger to themselves or others or is severely distressed
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
What are the types of dementia?
- Alzheimers
- Vascular dementia
- Mixed Alzeimers/Vascular
- Dementia with Lewy Bodies
- ‘Reversible’ causes
How does Alzheimer’s present?
- Slow, insidious onset
- Loss of recent memory first
- progressive functional decline
What are the risk factors for Alzheimer’s?
- Age
- Vascular risk factors
- Genetics
How does vascular dementia present?
- Classically step-wise deterioration
- Executive dysfunction may predominate rather than memory impairment
- Associated with gait problems often
What are the risk factors for vascular dementia?
Often have known vascular risk factors
- T2DM
- AF
- IHD
- PVD
How does dementia with Lewy bodies present?
- May have parkinsonism
- Often very fluctuant
- Hallucinations common
- Falls common
How does fronto-temporal dementia present?
Onset usually earlier
Early symptoms differ from other dementias
- Behavioural changes
- Language difficulties
- Memory is often unaffected early on
Usually lack insight into their difficulties
How is dementia diagnosed?
- MMSE
- MOCA
- History
What are the problems with the tests used in the diagnosis of dementia?
- Can be culturally/ generationally/ intellectually specific
- Can be falsely reassuring and should therefore be used as monitoring tools
What non-pharmacological therapy is there for dementia?
- Support for person and carers
- Cognitive stimulation
- Exercise
- Environmental design
- Avoiding changes in environment/social support etc
- Advanced care planning
What pharmacological forms of management is there for dementia?
Cholinesterase inhibitors
- Mainly used in Alzheimer (Galantamine licensed in mixed dementia, Rivastigmine in Dementia with Lewy Bodies)
- Not a cure
Anti-psychotics
- Should be avoided If possible
- Start low and go slow
What reversible causes of dementia are there?
- Hypothyroidism
- Intracerebral bleeds/tumours
- B12 deficiency
- Hypercalcaemia
- Normal pressure hydrocephalus
- Depression
What is capacity?
The capability of someone to make decisions about their care
If someone does not have capacity, who may have the ability to make decisions for them?
Welfare POA or guardian
