Neurocognitive Disorders + MHA

Question 1

Define delirium and what are it’s three subtypes?

Answer 1

Definition: Acute and fluctuating disturbance in attention and cognition often accompanied by a change in consciousness. It is reversible and seen in the elderly.

Subtypes:
1. Hyperactive - Inc. psychomotor activity, restlessness, agitation and hallucination
2. Hypoactive - lethargy, dec. responsiveness and withdrawal
3. Mixed - hyperactive and hypoactive features

Question 2

Difference between delirium and dementia

Mnemonic - OCD CAMPS:
Onset
Course
Duration
Consciousness
Attention
Memory
Psychomotor
Sleep/wake cycle

Answer 2

Delirium Vs Dementia:
O - Rapid (hrs/days) vs Slow (mths/yrs)
C - Fluctuating vs progressive
D - Reversible (days/wks) vs irreversible (mths/yrs)
C - Altered vs normal
A - significant inattention + lack of conc vs normal
M - Immediate recall bad vs normal immediate recall
P - Hyper/hypoactive vs normal
S - often reversed vs often normal

Question 3

Causes of delirium

Mnemonic - DELIRIUMS

Answer 3

D - drugs and alcohol
E - eyes, ears and emotional disturbances
L - low output state (MI, PE, HF, COPD, acute resp dep.)
I - infection
R - retention (urine/stools)
I - ictal (seizure activity)
U - underhydration/nutrition
M - metabolic disorders (thyroid, Wernicke’s)
S - subdural haematoma, sleep deprivation

Question 4

Sx of delirium

Answer 4

• Disorientation
• Hallucinations (visual/auditory)
• Inattention
• Memory problems
• Mood changes (e.g. sundowning - agitation worsening in late afternoon/evening)
• Disturbed sleep

Question 5

Ix for delirium

Including tools used for delirium assessment

Answer 5

Tools:
* 4AT
* CAM

Ix:
* Bedside - ECG, urine, bladder scan
* Bloods - FBC, U&E, LFTs, TFTs
* Imaging - X-ray, USS, CT or MRI head

Question 6

Tx of delirium

Answer 6

Treat underlying cause!
Calm pt and reassure them
Low lights and calm environment
Maintain regular sleep-wake cycle

If extremely agitated:
Small dose of haloperidol or lorazepam

Question 7

Define dementia

Answer 7

A syndrome of chronic/progressive nature which involves impairment of multipls higher cortical functions such as memory, thinking, orientation, comprehension and language.

Question 8

A score of what on a MMSE (mini-mental state examination) out of 30 would suggest the following:
1. Mild dementia
2. Moderate dementia
3. Severe dementia

Answer 8

1. Mild: 20-24
2. Moderate: 13-20
3. Severe: <12

Question 9

What is the cause of Alzheimer’s?

Answer 9

Abnormal phosphorylation of tau protein leads to build up as amyloid plaques in the neural cortex and brain vessel walls.

Tau protein would usually protect neurones against calcium influx.

Therefore a deficit in acetylcholine leads to forebrain damage.

Question 10

Sx of Alzheimers?

Answer 10

4 A’s:
1. Amnesia (recent memories lost first)
2. Aphasia (word-finding problems, speech muddled and disjointed)
3. Agnosia (recognition problems)
4. Apraxia (inability to carry out skilled tasks despite normal motor function)

Question 11

Tx of Alzheimer’s?

Answer 11

Mild-moderate:
Cholinesterase inhibitors - donepezil (1st line) rivastigamine (better for hallucinations) and galantamine

Severe:
MDA inhibitor - memantine

Question 12

What causes vascular dementia?

Answer 12

Impaired blood flow to areas of the brain due to vascular damage (i.e. micro-infarcts in pts with CVD)

Question 13

What is the progression pattern of each of the following:
1. Alzheimer’s
2. Vascular dementia

Answer 13

1. Straight line decline
2. ‘Step wise’ progression - often starts suddenly following a TIA/stroke

Question 14

What would imaging show in someone with vascular dementia and how would you manage a patient with vascular dementia?

Answer 14

Neuro-imaging can show significant small vessel disease

Mx - tx underlying vascular RF

Question 15

What is the cause of lewy body dementia?

Answer 15

Abnormal protein deposits called Lewy Bodies (alpha synuclein) within cells as inclusions cause cognitive decline associated with parkinsonism.

Question 16

What’s the difference between Lewy body dementia and a Parkinson’s disease dementia?

Answer 16

Lewy body dementia:
* Dementia + movement disorder develop within a year of each other

Pakrkinson’s disease dementia:
* Dementia + movement disorder develop a year apart

Question 17

Sx of Lewy body dementia?

Answer 17

• Parkinsonism sx (rigidity, tremor and bradykinesia)
• Visual hallucinations - classically of small creatures/children/figures (Lilliputian bodies)

Question 18

Sx of fronto-temporal dementia?

Answer 18

Cognitive impairment
Personality change
Repetitive checking behaviour
Disinhibition (inability to withhold an inappropriate)
Constructional apraxia (i.e. failure to draw interlocking pentagons)

Question 19

What are the 3 main variants of fronto-temporal dementia and describe their sx?

Answer 19

1. Behavioural (60%) - loss of social skills, personal conduct awareness , disinhibition and repetitive behaviour
2. Semantic (20%) - inability to remember words for things i.e. calling them ‘thingy’
3. Progressive non fluent aphasia (20%) - pt can’t verbalise (speech is laboured and difficult)

Question 20

RF for fronto-temporal dementia?

Answer 20

Repetitive head injury
Classically presents at a younger age than other forms of dementia
Pick’s disease

Question 21

Diagnosis of dementia?

Answer 21

Cognitive assessments - MMSE, 6-CIT
Bloods - FBC, U&E, LFTs, B12, folate etc
Neuroimaging - CT or MRI

Question 22

What are some things to consider when assessing holistic risk in patients with dementia?

Hint - mnemonic: HOW SAFE

Answer 22

• HOme safety (gas)
• Wandering
• Self neglect
• Abuse
• Falls
• Eating

Question 23

According to the Mental Health Act 1983, what is the criteria for a patient to be detained?

Answer 23

They have a mental disorder that poses significant
risk to themselves or others, and treatment in the
community is not possible because of this

Question 24

• What is holding powers?
• Describe the following sections:
  1. Section 5(4)
  2. Section 5(2)

Answer 24

Holding powers - stop pt from leaving a ward
1. Section 5(4): Nurse holding power, lasts 6 hours, to wait for medical assessment
2. Section 5(2): Doctors’ holding power, lasts 72 hours, to allow for MHA to be organised

Question 25

Describe the following sections:
1. Section 2
2. Section 3

They both require the same number of professionals, who are they?

Answer 25

They require: 1 AMHP + 2 Section 12 Approved doctors

1. Section 2: allows for pt to be admitted to hospital, for 28 days, to assess whether they are suffering from a mental disorder
2. Section 3: allows for pt to be admitted to hospital for treatment if their mental disorder requires treatment in hospital, lasts for 6 months

AMHP = Approved Mental Health Professional

Question 26

Describe section 4 of the MHA?

Answer 26

• Requires 1 doctor and 1 AMHP
• Lasts for 72 hours
• Designed for emergencies when applying Section 2 would cause an unnecessary delay. Typically followed by a transition to section 2.

Question 27

Describe the following sections of the MHA (police powers):
1. Section 136
2. Section 135

Answer 27

1. Section 136: lasts 24 hrs, person suspected to have a mental disorder in a public place therefore is taken to a place of safety
2. Section 135: lasts 36 hours, to enter someone’s property and take them to a place of safety, needs courts approval