L12 - Confusion Flashcards
Causes of confusion on the elderly
Delirium Dementia Drugs Depression Endocrine/ metabolic defects
Delirium
Acute change in consciousness (feeling drowsy) and cognition that fluctuates
- inattention
- confusion
Cognition
Ability to gain and understand new knowledge
E.g making new memories
Problem solving
Understand language
Depression
Change in mood and feeling of self worth
Dementia
Cognitive decline due to diseases of the brain
Progressive
Impairment in memory, intellect and personality
Drugs that can cause confusion
Morphine
Cocaine
Alcohol
Zopiclone
Metabolic disturbances that can cause confusion
Hyper/ hypothyroidism
Hyper/ hypocalcaemia
Vitamin B12 deficiency
Normal pressure hydrocephalus
Early and late onset dementia
Early - before 65 yrs old
Late - after 65 yrs old
Types of dementia
Alzheimer’s disease Lewy Body dementia Vascular dementia Fronto - temporal dementia AIDS dementia complex
Tests to assess cognitive function
Mini mental state examination (MMSE)
Montreal cognitive assessment (MOCA) - used by neurology department
Macroscopic changes of Alzheimer’s disease
Global brain atrophy
Mostly frontal, parietal and temporal lobe
Affects hippocampus - memory loss
Sulcus widening
Enlarged 3rd and 4th interventricular space
Microscopic changes of Alzheimer’s disease
Senile amyloid plaques from the breakdown of beta amyloid precursor proteins
Increased neurofibrillary tau tangles - increases acetylcholinesterase therefore decreasing Ach
Neuronal death
Treatment of Alzheimer’s disease to treat symptoms
Acetylcholinesterase inhibitors increases acetylcholine
Early onset genetic factors
- beta Amyloid precursor protein mutation
- presenilin 1
- presenilin 2
Late onset genetic factors
Apolipoprotein E gene - increased permeability of the brain to amyloid plaques
Presenting complaint of Alzheimer’s disease
Memory loss
Loss of vision-spatial awareness - get lost
Difficulty in using language, calculations and everyday activities
Medication
Acetylcholinesterase inhibitors:
- donepezil
- galantamine
- rivastigmine
Glutamate inhibitors - preventing excitotoxicity
- memantine
Pathophysiology of Lewy body dementia
Aggregation of alpha synuclein protein Found in cytoplasms Deposits in the: - substantia nigra - temporal lobe - frontal lobe - cingulate gyrus
Lewy body presenting complaint
- fluctuating cognition with variation in attention and alertness
- visual hallucinations
- Parkinsonism - festigating gait and flexed posture
How does Parkinson’s disease differ from Lew body dementia?
Parkinson’s disease:
- early Parkinson’s symptoms
- late cognitive decline
- tremor
- bradykinesia
- lead pipe rigidity
Lewy body dementia:
- early cognitive decline
- late Parkinson’s symptoms
- no tremor of rigidity
How to treat Lewy body dementia
Acetylcholineesterase inhibitors:
- donepezil
- galantamine
- rivastigmine
Glutamate inhibitor:
- memantine
Fronto- temporal dementia
2nd common cause of early onset dementia
55 - 65 yrs old
Atrophy of frontal and temporal lobes
Presenting complaint of fronto- temporal dementia
Frontal lobe:
- altered behaviour
- altered personality
- bad social conduct - less control over appropriateness
- Broca’s dysphasia
- primitive reflexes I.e. grasp reflex and palmomental reflex
Temporal lobe:
- hippocampus - short/ long term memory impairment
- Wernicke’s dysphasia
Palmomental reflex
Stroke thenar eminence in baby, open mouth
Also seen in fronto - temporal dementia
Vascular dementia
Caused by ischaemic or haemorrhagic stroke - cerebrovascular event
Risk factors of vascular dementia
Hypertension Hypercholesterolaemia Smoking Diabetes Vascular disease
Treatment of vascular dementia
Treat the risk factors
Progression of vascular dementia
Step - wise deterioration of cognitive function with focal neurological symptoms
- lacuna stroke - brain cognition decreases but then stabilises
- recurrent
AIDS - dementia complex
Increased prevalence
HIV infected macrophages enter the brain and cause indirect damage to neurones
Rapidly progressive
Insidious onset
Presenting complaint of AIDS dementia complex
Ataxia Cognitive impairment Psychomotor retardation Tremor Dysarthria - joint pain Incontinence
Treatment of AIDS dementia complex
Treat HIV with antivirals
Common investigations for all dementia cases
Within 6 months of new diagnosis:
- FBC
- U+ Es
- LFTs
- CRP
- thyroid function test
- random blood sugar
- vitamin B12 and folate
- routine syphilis tests if indicated
Bio-psycho social model
Refer to health care professional to manage symptoms e.g. district nurses and Age UK
- feelings of isolation
- impairment in daily activities
- financial burden
Types of delirium
Hyperactive: increased motor activity and increased excitability
Hypo-active: decreased motor activity and low mood with decreased interaction
Mixed
Causes of delirium
Drug toxicity:
- withdrawal of alcohol, coffee, cocaine or benzodiazepines
- opiates, anti - histamine, dopamine agonists, levodopa
Endocrine
- hyper or hypothyroidism
- Addison’s disease
- Cushing’s disease
Liver failure
Intracranial
- stroke
- epilepsy
- cerebral abscess
- haemorrhage
Renal failure - hyperureamia
Infection
Urinary and faecal retention
Metabolic
- hypoxia
- electrolyte imbalance
Delirium investigations
FBC LFTs U+Es CRP Thyroid function test Blood sugar Blood culture - sepsis
Bedside tests:
- urine dip +/- culture
- oxygen saturation
Radiological
- CXR
- CT (if appropriate)
Confusion screening
Review drug history
Rule out causes
Treatment of delirium
Treat underlying cause
Rehydrate
Calm environment
Haloperidol if essential
Difference between delirium and dementia
Delirium:
- rapid onset
- fluctuating
- hallucinations
- impaired consciousness
- speech a can be slow or fast
- reduced GCS
Dementia:
- slow progression
- normal GCS
- hallucinations rare
- steady decline
- speech slow
How to assess consciousness
Check pulse and breathing
Sternal rub
Trapezius squeeze
Fingernail pressure test
