LO2 Cognitive assessment. Delirium, dementia and depression Flashcards
What is the definition of delirium?
Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1–2 days. It is a serious condition that is associated with poor outcomes. However, it can be prevented and treated if dealt with urgently.
What is the definition of depression?
Depression is a broad and heterogeneous diagnosis. Central to it is depressed mood and/or loss of pleasure in most activities. Severity of the disorder is determined by both the number and severity of symptoms, as well as the degree of functional impairment. A formal diagnosis using the ICD-10 classification system requires at least four out of ten depressive symptoms, whereas the DSM-IV system requires at least five out of nine for a diagnosis of major depression (referred to in this guideline as ‘depression’). Symptoms should be present for at least 2 weeks and each symptom should be present at sufficient severity for most of every day. Both diagnostic systems require at least one (DSM-IV) or two (ICD‑10) key symptoms (low mood,[1] loss of interest and pleasure[1] or loss of energy[2]) to be present.
What are the 3 main tools for delirium screening?
Confusion assessment method (CAM)
Single question in delirium (SQiD)
4AT
What does the CAM involve?
Feature 1: Acute Onset or Fluctuating Course
This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
Feature 2: Inattention
This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention,for example, being easily distractible, or having difficulty keeping track of what was being said?
Feature 3: Disorganized thinking
This feature is shown by a positive response to the following question: Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Feature 4: Altered Level of consciousness
This feature is shown by any answer other than “alert” to the following question: Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])
The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.
What does the AMT4 involve?
• Alertness • AMT4 1. Age 2. DOB 3. Current location 4. Current year • Attention • Immediate history i.e. has the patient's cognitive condition changed acutely or been fluctuating? 4+= Possible delirium/cognitive impairment 2-3= possible cognitive impairment 0-1= Delirium unlikely
If delirium is not present, mild cognitive impairment can be screened via Abbreviated Mental Health Score (AMTS) with a score of <7 indicating chance of dementia/delirium. What questions are in the AMTS?
- Age
- Time (to the nearest hour)
- Year
- Location
- I want you to remember this address – 42 West Street. Ask them to recall at the end of the test
- Do you know who I am? Do you know who that is (point to nurse/family member)?
- Name of the current Prime Minister
- DOB
- Year when WW2 ended?
- Can you count down from 20 to 1?
What is the geriatric depression score? What questions are involved? What score indicates depression?
Are you basically satisfied with your life?
Have you dropped many of your activities or interests?
Do you feel that your life is empty?
Do you often feel bored?
Are you in good spirits most of the time?
Are you afraid that something bad is going to happen to you?
Do you feel happy most of the time?
Do you often feel helpless?
Do you prefer to stay at home, rather than going out and doing new things?
Do you feel you have more problems with your memory than most?
Do you think it is wonderful to be alive?
Do you feel pretty worthless the way you are now
Do you feel full of energy?
Do you feel that your situation is hopeless?
Do you think that most people are better off than you are?
Greater than 5 indicates depression
What are the 5 components of the MMSE score?
1) orientation
2) registration
3) attention and calculation
4) recall
5) language
What is the 6-CIT test? What does it consist of?
The 6-CIT is used as a dementia screening tool in primary care, it is marked out of 28 (scores for incorrect answers indicated below); scores >8 significant:
What year is it? (4)
What month is it? (3)
Give the patient an address with five components to remember “John Smith, 42, West Street, London”
What time is it to the nearest hour? 3
Count backwards from 20 – 1. 1 error = 2, >1 error = 4
Say the months of the year in reverse. 1 error =2, >1 error = 4
Repeat address. 1 error = 2, 2 errors = 4, 3 errors = 6, 4 errors = 8, 5 errors = 10
When is fluctuation worse in delirium?
At night/in the dark/on waking up
What is depressive pseudodementia?
short Hx, pt. is despairing of their poor memory, insight present in depression, there may be a classical depressive sleep pattern, many ‘don’t know’ responses, memories are accessible with hints and clues
What are the DMS-IV criteria for delirium?
- Disturbance of consciousness
- Worsening confusion
- Acute onset with fluctuating course
- Due to a medical condition, substance intoxication and/or substance withdrawal, multiple co-morbidities
What are the common causes of delirium? (think mnemonic)
Common causes include (mnemonic DELIRIUM-P):
Drug intoxication or withdrawal (anticholinergics, anxiolytics, antidepressants, anticonvulsants, opiates, alcohol, levodopa, sedatives)
Electrolyte imbalance (hypo-/hypernatremia, hypercalcaemia)
Liver failure, Low O2
Intracranial pathology (stroke, infection, injury)
Renal failure, Retention (urinary retention, constipation, faecal impaction)
Infection (chest, UTI, or cellulitis)
Uraemia and fluid imbalance
Metabolic (endocrine imbalance: hypo-/hyperglycaemia, hypo-/hyperthyroidism)
Pain, Postoperative
What are the risk factors for delirium?
> 65y/o; dementia/previous cognitive impairment; hip fracture; acute illness; psychological agitation, e.g. pain
What are risk factors for delirium?
Age Pre-existing cognitive impairment Previous episode of delirium Current hip fracture Current severe physical illness Sensory impairment: hearing or visual
What should examination into a delirious patient involve?
- Conscious level = GCS/AVPU
- Cognition function = 4AT, AMTS, MMSE or Clock-drawing test
- Physical examination on evidence of infection (lung, abdomen, skin)
- Infection screen remove bandages and assess pressure areas
- Neurological examination
- Abdominal examination inc. DRE for constipation or urinary retention
- Check O2 saturation
