Geriatrics Flashcards
Precipitating factors for Delirium
PINCHME (Mnemonic): Pain Infection Nutrition Constipation Hydration Medication e.g, opiates Environment
Factors that distinguish delirium from dementia
Acute onset
Impaired consciousness
Fluctuation of symptoms - typically worse at night
Abnormal perceptions e.g, illusions and hallucinations
Agitated
Two types of delirium
Hyperactive
Hypoactive
Delirium investigations screen
Observations
Bloods - FBC, U&E, LFTs, CRP, TFT, folate, B12, glucose, calcium
CXR - look for infection
Urine dip - look for infection
CT head - rule out stroke or intracranial haemorrhage
Management of delirium
Treat underlying cause Reorientation Modify environment if required DOLS Sedation - only use as last resource, have to be a risk to themselves or others. Give haloperidol or lorazepam (haloperidol is contraindicated in Parkinson’s)
What are the short assessment tools that can be used to assess cognition
6 item cognitive impairment test (6ICT)
Abbreviated mental test score (AMTS)
What are the longer questionnaires that can be used to assess memory and cognition
What scores would indicate dementia?
Mini mental state examination (MMSE): <24/30
Addenbrooke’s cognitive examination (ACE-III): <82/100
4 types of dementia
Alzheimer’s
Vascular
Lewy body
Frontotemporal
Genes associated with Alzheimer’s
Apoprotein E allele E4
Amyloid precursor protein (AFP) - link with Down’s syndrome
Pathophysiology of Alzheimer’s
Beta amyloid protein deposits
Neurofibrillary tangles - made from accumulation of tau
5 A’s of Alzheimer symptoms
Amnesia - progressive memory decline
Agnostic - inability to recognise external stimuli (e.g people)
Apraxia - difficulty in performing coordinated motor tasks
Aphasia - difficulty speaking (later sign)
Associated behaviours - e.g, psychiatric, behavioural, personality change
Non pharmacological management of Alzheimer’s
Psychological - group cognitive stimulation, activities to promote exercise and wellbeing
Social - Occupational therapist, carers etc
Biological management of Alzheimer’s
AChE - e.g, donepezil, rivastigmine (1st line)
Glutamate receptor antagonists - memantine (2nd line)
What investigation must you do before starting patients on an Acetylcholinesterase inhibitor
ECG - as medications can alter heart rhythms
Which AChE is contraindicated in patients with bradycardia
Donepezil
Which AChE is treatment of choice for patients with co existing cardiovascular disease
Rivastigmine
What do you need to check before starting patients on memantine
Renal function (eGFR) - as memantine should be avoided in patients with renal failure
Which antipsychotic is the one of choice in Alzheimer’s if necessary
Quetiapine
What are the types of vascular dementia
Stroke related - after multi or single infarct
Subcortical - caused by small vessel disease
Mixed - mix of vascular and Alzheimer’s
Presentation of vascular dementia
History of sudden onset or stepwise deterioration
This is due to infarct in the brain causing brain damage
Patients may have difficulty with attention, concentration and memory
Management of vascular dementia
No specific medical management (unless they have mixed dementia with Alzheimer’s)
Management is mainly psychological and social.
Aim to address cardiovascular risk factors to slow progression and prevent further infarcts
Pathophysiology of Lewy body dementia
Alpha synuclein cytoplasmic inclusions (lewy bodies)
These accumulate in the substantia nigra, paralimb and neocortical areas
Features of Lewy body dementia
Progressive cognitive impairment
Symptoms tend to fluctuate (in contrast to other forms of dementia)
Parkinsonism - develops later in disease
Visual hallucinations
Diagnosis of Lewy body dementia
Usually clinical
DaTscan - type of SPECT brain scan used to help diagnosis
