Neurocognitive Disorders + MHA Flashcards
Define delirium and what are it’s three subtypes?
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
Difference between delirium and dementia
Mnemonic - OCD CAMPS:
Onset
Course
Duration
Consciousness
Attention
Memory
Psychomotor
Sleep/wake cycle
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
Causes of delirium
Mnemonic - DELIRIUMS
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
Sx of delirium
- Disorientation
- Hallucinations (visual/auditory)
- Inattention
- Memory problems
- Mood changes (e.g. sundowning - agitation worsening in late afternoon/evening)
- Disturbed sleep
Ix for delirium
Including tools used for delirium assessment
Tools:
* 4AT
* CAM
Ix:
* Bedside - ECG, urine, bladder scan
* Bloods - FBC, U&E, LFTs, TFTs
* Imaging - X-ray, USS, CT or MRI head
Tx of delirium
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
Define dementia
A syndrome of chronic/progressive nature which involves impairment of multiple higher cortical functions such as memory, thinking, orientation, comprehension and language.
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
- Mild: 20-24
- Moderate: 13-20
- Severe: <12
What is the cause of Alzheimer’s?
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.
Sx of Alzheimers?
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)
Tx of Alzheimer’s?
Mild-moderate:
Cholinesterase inhibitors - donepezil (1st line) rivastigamine (better for hallucinations) and galantamine
Severe:
MDA inhibitor - memantine
What causes vascular dementia?
Impaired blood flow to areas of the brain due to vascular damage (i.e. micro-infarcts in pts with CVD)
What is the progression pattern of each of the following:
1. Alzheimer’s
2. Vascular dementia
- Straight line decline
- ‘Step wise’ progression - often starts suddenly following a TIA/stroke
What would imaging show in someone with vascular dementia and how would you manage a patient with vascular dementia?
Neuro-imaging can show significant small vessel disease
Mx - tx underlying vascular RF
What is the cause of lewy body dementia?
Abnormal protein deposits called Lewy Bodies (alpha synuclein) within cells as inclusions cause cognitive decline associated with parkinsonism.
What’s the difference between Lewy body dementia and a Parkinson’s disease dementia?
Lewy body dementia:
* Dementia + movement disorder develop within a year of each other
Pakrkinson’s disease dementia:
* Dementia + movement disorder develop a year apart
Sx of Lewy body dementia?
- Parkinsonism sx (rigidity, tremor and bradykinesia)
- Visual hallucinations - classically of small creatures/children/figures (Lilliputian bodies)
Sx of fronto-temporal dementia?
Cognitive impairment
Personality change
Repetitive checking behaviour
Disinhibition (inability to withhold an inappropriate)
Constructional apraxia (i.e. failure to draw interlocking pentagons)
What are the 3 main variants of fronto-temporal dementia and describe their sx?
- Behavioural (60%) - loss of social skills, personal conduct awareness , disinhibition and repetitive behaviour
- Semantic (20%) - inability to remember words for things i.e. calling them ‘thingy’
- Progressive non fluent aphasia (20%) - pt can’t verbalise (speech is laboured and difficult)
RF for fronto-temporal dementia?
- Repetitive head injury
- Classically presents at a younger age than other forms of dementia
Frontotemporal dementia is also known as pick’s disease
Diagnosis of dementia?
Cognitive assessments - MMSE, 6-CIT
Bloods - FBC, U&E, LFTs, B12, folate etc
Neuroimaging - CT or MRI
What are some things to consider when assessing holistic risk in patients with dementia?
Hint - mnemonic: HOW SAFE
- HOme safety (gas)
- Wandering
- Self neglect
- Abuse
- Falls
- Eating
According to the Mental Health Act 1983, what is the criteria for a patient to be detained?
They have a mental disorder that poses significant
risk to themselves or others, and treatment in the
community is not possible because of this
- What is holding powers?
- Describe the following sections:
1. Section 5(4)
2. Section 5(2)
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
Describe the following sections:
1. Section 2
2. Section 3
They both require the same number of professionals, who are they?
They require: 1 AMHP + 2 Section 12 Approved doctors
- Section 2: allows for pt to be admitted to hospital, for 28 days, to assess whether they are suffering from a mental disorder
- 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
Describe section 4 of the MHA?
- 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.
Describe the following sections of the MHA (police powers):
1. Section 136
2. Section 135
- Section 136: lasts 24 hrs, person suspected to have a mental disorder in a public place therefore is taken to a place of safety
- Section 135: lasts 36 hours, to enter someone’s property and take them to a place of safety, needs courts approval
