Neuro15 - Confusion in the Elderly Patient (Delirium & Dementia)

Question 1

3 main groups of causes of confusion in elderly patients (3Ds)

Answer 1

1. ) Delirium - acute change in consciousness/cognition
2. ) Depression - change in mood/feeling of self-worth
3. ) Dementia - cognitive decline due to brain disease

Question 2

Delirium

Definition
Investigations
Management
Complications

Answer 2

1. ) Definition - acute onset (1-2 days) of confusional state w/ altered level of consciousness
   - hyperactive (more common): agitation, confusion, hallucinations, wandering, aggression
   - hypoactive: lethargy, withdrawn, drowsy, inattention
2. ) Investigations
   - basic obs/EWS, GCS/AVPU
   - bloods - FBC, U+Es, LFTs, TFTs, clotting, bone profile, haematinics, glucose, blood cultures
   - urinalysis, CXR, CT Head
   - AMTS or MMSE
3. ) Management
   - treat the underlying cause
   - environment orientation: clocks, familiar objects, control noise, adequate lighting, ambient temperature
   - pharmacological (last-line): haloperidol or lorezapam
4. ) Complications
   - increased mortality, prolonged admission, increased risk of developing dementia
   - can take up to 3 months to return to baseline whilst some never get back to their baseline

Question 3

Causes of Delirium (CHIMPS PHONED)

C
H
I
M
P
S
P
H
O
N
E
D

Answer 3

1. ) Constipation - often causes hypoactive delirium
2. ) Hypoxia
3. ) Infection/Intracranial
   - UTI, sepsis, meningitis, pneumonia
   - stroke, haemorrhage, epilepsy, abscess

3.) Metabolic Disturbance - dehydration, electrolyte imbalance, normal pressure hydrocephalus

4. ) Pain - esp if uncontrolled
5. ) Sleeplessness
6. ) Prescriptions
   - anticholinergics, anti-depressants, anti-histamines
   - opiates, beta-blockers, corticosteroids, benzos
   - dopamine agonists, lithium, calcineurin inhibitors

7.) Hypothermia/Pyrexia

8. ) Organ Dysfunction
   - hepatic or renal failure
   - endo: hyper/hypothyroidism, Cushing’s, Addison’s
9. ) Nutrition - malnutrition
10. ) Environmental Changes - disorientation
11. ) Drugs
    - OTC, illicit drugs, smoking
    - withdrawal: alcohol, benzos, cocaine, coffee

Question 4

4 general features of dementia

Definition
Onset
Investigations x4
Pharmacological Treatment x4

Answer 4

1.) Definition - set of diseases characterised by a progressive decline in higher cortical function

2. ) Onset - can be early or late
   - early onset is <65, late-onset is 65+
   - prion diseases and aggressive brain tumours are the most common cause of rapid-onset dementia in young people
3. ) Investigations
   - general blood tests, random BM, vit B12/folate
   - syphilis testing if risk is identified in the history
4. ) Pharmacological Treatment - AChEi or memantine
   - AChEi: donepezil, galantamine, rivastigmine
   - NMDA antagonist: memantine

Question 5

Delirium vs Dementia

Onset and Progression
Hallucinations
Speech
Consciousness and GCS

Answer 5

1. ) Onset and Progression
   - delirium: rapid onset with fluctuating course
   - dementia: slow onset and steady decline
2. ) Hallucinations - present in delirium, rare in dementia
3. ) Speech - can both be slow but delirium can be fast
4. ) Consciousness and GCS - reduced in delirium

Question 6

5 features of Alzheimer’s dementia

Pathophysiology x2
Macroscopic Changes x3
Genetics x3
Symptoms x4
Treatment x2

Answer 6

1. ) Pathophysiology - abnormal proteins kills neurones
   - ß-amyloid plaques: accumulate and clump together between neurones due to abnormal breakdown
   - neurofibrillary tau tangles: tau protein is abnormal and the microtubule structures collapse inside the neurone
2. ) Macroscopic Changes
   - global atrophy: frontal, parietal, temporal lobes
   - sulcus widening
   - enlarged 3rd and 4th interventricular spaces
3. ) Genetics - defects in these proteins:
   - early onset: ß-amyloid precursor protein, presenilin 1/2
   - late-onset: apolipoprotein E gene
4. ) Symptoms - insidious onset with slow progression
   - ↓memory, ↓spatial navigation
   - ↓executive functions: language, calculation
5. ) Treatment - AChE inhibitors or memantine
   - monotherapy: AChEi or memantine (if severe)
   - memantine if AChEi are contraindicated/intolerant or are already on an AChEi for other reasons

Question 7

3 features of Lewy body dementia

Pathophysiology (+4 locations)
Symptoms x3
Treatment x3

Answer 7

1. ) Pathophysiology - presence of Lewy bodies
   - aggregation of alpha-synuclein protein in cytoplasm
   - fronto-temporal lobe, substantia nigra, cingulate gyrus
2. ) Symptoms - gradually progressive, clinical triad
   - fluctuating cognition, attention and alertness
   - visual hallucinations
   - parkinsonian features: shuffling gait, flexed posture
3. ) Treatment - AChE inhibitors or memantine
   - donepezil or rivastigmine (both if severe)
   - galantamine if others not tolerated
   - memantine if AChE inhibitors contraindicated

Question 8

3 features of fronto-temporal dementia

Pathophysiology
Frontal Lobe Symptoms x4
Temporal Lobe Symptoms x2

Answer 8

1. ) Pathophysiology - atrophy of frontal/temporal lobe
   - 2nd most common cause of early onset (peak: 55-65)
2. ) Frontal Lobe Symptoms
   - altered behaviour, personality, social conduct
   - appears disinhibited and apathetic
   - expressive dysphasia (Broca’s area)
   - primitive reflexes (PMC): grasp and palmomental reflex
3. ) Temporal Lobe Symptoms
   - short/long-term memory impairment
   - receptive dysphasia (Wernicke’s area)

Question 9

3 features of vascular dementia

Pathophysiology
Symptoms
Treatment

Answer 9

1. ) Pathophysiology - cerebrovascular disease (i.e stroke)
   - risk factors: hypertension, diabetes, smoking etc.
2. ) Symptoms - step-wise deterioration of cognitive function with focal neurological symptoms
3. ) Treatment - treated pharmacologically if they also have Alzheimer’s, Parkinson’s or Lewy body dementia

Question 10

3 features of AIDS-Dementia complex (ADC)

Pathophysiology
Symptoms x6
Treatment

Answer 10

1. ) Pathophysiology - HIV-infected macrophages enter the brain and cause indirect damage to neurones
   - gradual onset but rapid progression
2. ) Symptoms
   - cognitive impairment, dysarthria, incontinence
   - psychomotor retardation, tremor, ataxia

3.) Treatment - treat HIV (anti-virals)