Geriatrics Flashcards
Confusion Assessment Method (CAM)
Four core features:
1) Inattention (examination: serial 7s, months backwards)
2) Acute onset and fluctuating course (history: collateral RN/family)
3) Disorganized thinking (observation: Patient making sense? “can a stone float on water?”)
4) LOC altered (observation: hypervigilant? somnolent? both?)
- Need 1 and 2 + either 3 or 4
Delirium: Work-up
Indications for neuroimaging:
1. Focal neurological sign
2. Head trauma
3. Fever + acute change (if encephalitis is suspected)
4. No other cause identified
5. Cannot do a neuro exam (hypoactive/somnolent)
Drugs :
Too much: opioids, benzodiazepines, sedatives, anticholinergics, intoxications/recreational,
Too Little: Pain undertreated, withdrawal (EtOH, benzo, opioid, nicotine)
+/- ASA/Tylenol/EtOH levels, tox screen
Infection/Inflammation:
Vitals, focal signs/sources of infection, cultures as appropriate (blood, urine, Chest XR, +/- LP)
Metabolic :
CBC, lytes, Cr, LEs/LFT, Calcium, VBG, glucose, TSH, B12, cortisol (hypoactive)
Environment:
Sensory deprivation (windowless room, hearing/vision aids), sensory overload, isolation from
familiar surroundings, absence of orientation (clock/calendar), restraints, disruption to rest/sleep
Retention Abdominal XR, bladder scan
Structural abnormality
Neuro: ex. seizure, stroke, hemorrhage (exam, +/- neuroimaging, EEG), Cardiac: MI/CHF
(Troponin, CK, ECG +/-BNP); Resp ex. asthma/COPDe, PE (+/-CTPA), Abdo exam, Derm (rashes),
MSK examination for source of pain, etc.
Delirium: Management
ABCs, consider thiamine, naloxone, O2, glucose depending on acuity
1. Treat the underlying causes and contributors
2. Supportive care (Non-Pharmacological)
– Multi-component intervention (see Prevention: relieve sensory deprivation, re-
orient, mobilize, ensure hydration/nutrition, sleep, cognitive stimulation)5
– Pharmacological intervention not effective as treatment1,2,3
3. Safety (Non-Pharmacological +/- Pharmacological)
– Address safety/behavioural disturbances to prevent complication
– Antipsychotics only if i) danger to self/others, ii) distressing psychosis, or iii)
preventing medically necessary care
* When needed: Low dose, short duration. Haldol or atypical antipsychotic 1st line
Quetiapine-Preferred agent if parkinsonism present.
Lorazepam-Preferred for withdrawal delirium,
neuroleptic malignant syndrome, 2nd line if parkinsonism.
Alzheimer’s Dementia
Diagnosis:
– Dementia AND
– Insidious onset, gradual progression (months-years)
– Atrophy on imaging [hippocampal –> global]
– Initial and most prominent deficits in:
* Memory (aka amnestic AD, most common)
* Non-amnestic
Vascular Dementia
- Diagnosis:
1. Cognitive impairment (any domain, but often frontal/executive) AND
2. Imaging evidence of cerebrovascular disease - Strokes
- White matter changes
- Microhemorrhages may be seen with severe uncontrolled hypertension
– Note: Microhemorrhages and cognitive impairment can also be seen in Cerebral Amyloid Angiopathy (CAA)
the underlying etiology of cognitive impairment in CAA is likely mixed amyloid and vascular pathology
+/- temporal relationship
Two main syndromes:
– post-stroke vascular dementia – “step-wise decline”
– subcortical ischemic syndrome – more common, insidious onset
* Imaging: periventricular white matter changes “moderate micro-angiopathic changes” +/- lacunar infarcts
* Clinically: frontal/executive syndrome
* Supportive findings: insidious onset, gait disturbance, “slow”
Dementia with Lewy Bodies (DLB)
- Diagnosis:
– Dementia and 2 of: - Fluctuating cognition
- Recurrent visual hallucinations
- Parkinsonism (bradykinesia, rest tremor,
rigidity) - REM sleep behaviour disorder
“1 year rule” to distinguish DLB and Parkinson’s
disease dementia (PDD)
– if dementia precedes or begins within 1 year of
onset of parkinsonism, then DLB
May also have 1 clinical feature
and 1 biomarker, including:
-Low dopamine uptake in basal ganglia
-Abnormal iodine-MIBG myocardial
scintigraphy
-Polysomnographic confirmation of REM
sleep without atonia
Supportive but non-diagnostic
features:
Sensitivity to antipsychotics, postural
instability, repeated falls, severe
autonomic dysfunction (constipation,
urinary incontinence, orthostasis,
syncope), hyposmia, hallucinations or
delusions, apathy/anxiety/depression
Behavioural Variant
Frontotemporal Dementia (bvFTD)
- Diagnosis:
– Dementia and 3 of - Disinhibition
- Apathy
- Loss of empathy
- Perseveration
- Hyperorality
- Executive dysfunction
Mixed Dementia
- Diagnosis:
– Dementia
– Any combination of syndromes
– Most common: - Alzheimer’s clinical syndrome AND
- Imaging findings consistent with vascular dementia
Rapidly Progressive Dementia
Evolving “more rapidly than expected for dementia syndrome” i.e. <1-2 years from first symptom
to dementia
* Causes:
– Degenerative (MOST COMMON): Prion disease (CJD) relatively common cause of RPD (up to 59% of cases),other neurodegenerative (up to 22%)*
– Inflammatory (Hashimoto’s encephalitis, NMDA-Encepahlitis), Vascular, Toxic, Metabolic, Neoplastic,
Infectious
Work-up:
– History and Physical Exam
– Investigations (consider the following):
* Labs lytes, ext lytes, liver panel, Cr, B12, TSH, ESR, CRP, ANA, ANCA, SPEP, anti-TPO, anti Tg, syphilis, lyme, HIV
* LP: CSF for cell count, protein, glucose, c+s, serologies, paraneoplastic panel (consult neuro)
* Neuroimaging: MRI indicated, consider MRV/ vessel wall imaging
* Other imaging as indicated (ex. paraneoplastic syndrome)
* Brain Biopsy: Indicated if there dx unclear and indentifiable focus on imaging
- Management: consider thiamine if poor nutritional status or alcohol, manage according to
etiology
Principles of Dementia Management
- Track progression/response to therapy
* Repeat subjective and objective assessments of cognition and function - Non-pharmacological and Pharmacological management
- Screen for and manage complications
* Geriatric review of systems: dysphagia, malnutrition, weight loss, incontinence, falls
* Behavioral and psychological symptoms of dementia
* Caregiver burnout
* Monitor for safety concerns: Stove on, water running, getting lost/wandering,
driving, firearms, power tools - Future planning
Pharmacotherapy for Alzheimer’s Dementia
- ChEIs (Donepezil, Galantamine, Rivastigmine)
– Trial is recommended for most patients with AD.
– Modest improvements in cognition, function, global assessment &
behaviour
– Side Effects: GI intolerance (anorexia), urinary incontinence, wild or
vivid dreams, bradycardia
– Avoid if pts have conduction defects (except RBBB), bradycardia, or
unexplained syncope. Use with caution in asthma, COPD, seizures, GI
bleeds, urinary incontinence
– When to discontinue: Intolerable side effects, lack of benefit, end- stage dementia (as no ongoing benefit), consider if significant cognitive
decline not explained by other precipitant - HOW to discontinue – taper by 50% every 4 weeks and monitor for clinical
worsening
Pharmacotherapy for Alzheimer’s Dementia
NMDA RA (Memantine)
– DOMINO-AD trial: memantine had benefit vs. placebo in moderate-
severe dementia (defined as MMSE 5-13), but no additional benefit
when combined with cholinesterase inhibitors
– Canadian guidelines say combination is rational, but not enough
evidence to recommend for or against
* DOMINO-AD trial (2012) no benefit to combination therapy
* Recent network meta-analysis concluded memantine + donepezil superior to
monotherapy and placebo.
Pharmacotherapy for Vascular Dementia
- Optimization of vascular risk factors (nonpharm & pharm)
- ChEIs (& memantine)
– 2020 Canadian Consensus Recommendations suggest that ChEIs and
memantine “may be considered” given diagnostic uncertainty and lack of other options
– Indicated in mixed AD & vascular dementia - ASA is not indicated with white matter changes only,
considered if micro-infarcts detected
-Glantamine
Pharmacotherapy for Dementia with Lewy Bodies
(DLB) & Parkinson’s Disease Dementia (PDD)
- ChEIs
– Good evidence cognition, global assessment, and
behavioural disturbance, hallucinations
– 1st trials used rivastigmine, but donepezil is better
tolerated
Behavioural & Psychological
Symptoms of Dementia (BPSD)
Clusters of symptoms:
– Psychosis: delusions, hallucinations, suspiciousness
– Aggression: verbal, physical, defensive, resistance to care
– Agitation: restlessness, anxiety, vocalization, repetitive actions,
pacing, wandering, hoarding
– Depression: sadness, guilt, hopelessness, irritability, suicidality
– Mania: irritability, euphoria, pressured speech, sexual
disinhibition
– Apathy: amotivation, withdrawn
Recent network meta-analysis3 demonstrated non-medication treatments (e.g. outdoor therapy, music and massage, massage and touch) were as or more efficacious than medications.
Pharmacologic:
* Some symptoms respond more to Rx than others
* Empiric pain control, Tylenol 1 g PO TID often
suffices1
* Risperidone2 approved by Health Canada (max 1
mg/d) only if all three conditions met: pure AD, non-
pharm Rx ineffective, and risk to self/others or
distressing psychotic symptoms
– Re-evaluate and taper q3months
