Geriatrics Flashcards
Delirium (acute confusional state)
clinical syndrome with acute onset, fluctuating change in mental status with inattention, disorganised thinking & altered levels of consciousness usually seen in >65y/o hospitalised pts
Characterised by high morbidity & mortality
Epidemiology of delirium
most common complication of hospitalisation in the elderly & high incidence in those with pre-existing cognitive impairment
↑ incidence with age
usually seen in those >65 y/o
Risk factors for delirium
age >65 yrs male sex pre-existing cognitive deficit e.g. dementia severe comorbidity previous delirium current severe illness/hip fracture ↑ pain drug use/dependence / substance misuse visual/hearing impairment poor mobility social isolation terminal illness ICU admission
Aetiology of delirium
Acute infections especially UTIs prescribed drugs e.g. benzos, analgesia (morphine), steroids, antiparkinson meds surgery/trauma urinary retention constipation sleep deprivation pain dehydration toxic substances (drugs/alcohol) neoplasia/malignancy
Subtypes of delirium
Hypoactive:
↓ psychomotor activity, apathy & quiet confusion
mostly seen in elderly pts
Hyperactive:
↑ psychomotor activity, agitation, delusions & disorientation
usually seen with substance abuse/withdrawal
Mixed delirium:
fluctuating psychomotor activity between hyper/hypoactive states
most common in general population
Presentation of delirium
usually acute presentation
fluctuating course throughout day
may be worse in evening (sundowning)
disorganised thinking, hallucinations (usually visual), cognitive deficits, impaired memory, emotional lability,, agitation, combativeness, disorientation, poor concentration, psychotic ideas (short duration & simple content)
Investigating delirium
Full physical examination Bloods (FBC/U&Es/LFTs/TFTs/Mg2+/Ca2+/creatinine/glucose) ECG Urine dip + MC&S CXR blood cultures ABG imagine/investigations for suspected cause
Management of delirium
treatment of underlying condition
Supportive care:
clear communication, reminders of day/time/location, familiar objects from home, involve family & carers
Environmental:
side room, control noise/lighting/temp
adequate nutrition
attention to continence / help with constipation
stop offending medication (e.g. benzos, morphine, warfarin, furosemide, lithium, TCAs, steroids)
Alzheimers dementia (AD)
a chronic neurodegenerative disease wait insidious onset & progressive but slow decline, may occur commonly with other types of dementia e.g. vascular
most common type of dementia
Characteristics of Alzheimer dementia (AD)
widespread cortical atrophy
extracellular senile/amyloid plaques made from beta amyloid
intracellular neurofibrillary tangles made from hyperposphorylated Tau
↓cholinergic function (acetylcholine deficiency)
Risk factors for Alzheimer dementia (AD)
caucasian heritage ↑ age hyperlipidaemia diabetes HTN smoking alcohol misuse Down's syndrome Genetics
Presentation of Alzheimer dementia (AD)
insidious onset & slow progression
short term memory impairment (episodic memory affected first)
disorientation (in time & place, subtle at first e.g. misplacing items/getting lost)
Presentation of Alzheimer dementia (AD)
insidious onset & slow progression
short term memory impairment (episodic memory affected first)
disorientation (in time & place, subtle at first e.g. misplacing items/getting lost)
nominal dysphasia
apathy
impaired ADLs
personality change / mood change
poor abstract thinking & judgement
psychiatric symptoms
agitation & irritability
impaired executive function (later on in disease)
Investigations for Alzheimer dementia (AD)
Bedside cognitive assessment (MMSE, MoCA, AMTS)
CT/MRI head (cortical atrophy)
Management of Alzheimer dementia (AD)
Person centred MDT care (memory assessment, memory enhancement strategies, therapies e.g. aroma/music therapy)
Pharmacological:
1st line: AChE inhibitors e.g. donepezil, galantamine, rivastigmine (for moderate AD)
2nd line: NMDA receptor antagonist e.g. memantine (if AChE contraindicated/as add on to AChE)
SSRIs as depression
Genetics of Alzheimer dementia (AD)
Amyloid precursor protein (APP)
Presenilin 1
Presenilin 2
ApoE4 (late onset)
NB ApoE3 = neutral & ApoE2 = portective
Vascular dementia (VD)
also know as multi infarct dementia, is a chronic progressive cognitive impairment caused by cerebrovascular disease leading to ischaemia / haemorrhage
2nd most common type of dementia
Sybtype of vascular dementia (VD)
its a spectrum of disease called vascular cognitive impairment of which vascular dementia is the worst
stroke related VD - multi/single infarct
subcortical VD - small vessel disease
mixed dementia - presence of both VD & AD
Inherited form of Vascular dementia
inherited as CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
RARE
Risk factors for vascular dementia (VD)
↑ age history of stroke/TIA AF HTN Diabetes smoking obesity CHD
Investigation/Assessment of vascular dementia (VD)
cognitive impairment screening
MRI/CT (may show infarcts / white matter changes)
NINDS-AIREN for diagnosis of probably VD (presence of cognitive decline interfering with ADLs, presence of CVD, relationship between the 2 suspected)
Management of vascular dementia (VD)
Individualised person centred care (cognitive stimulation programmes, therapies, multi sensory stimulation)
consider AChE inhibitors or memantine if comorbid Alzheimers
Frontotemporal dementia
progressive neurodegenerative disease of the frontal and/or temporal lobe generally due to mutations of proteins leading to lobar atrophy
3rd most common type of dementia
Onset of Frontotemporal dementia
usually age <65yrs
i.e. earlier than other dementias