Old Age Psychiatry Flashcards
What is delirium?
Also referred to as an acute confusional state and is a medical emergency
It involves impaired consciousness and impaired cognitive function
What are the different types of delirium?
Hypoactive, mixed, hyperactive
What are the characteristics of hypoactive delirium?
Lethargy, decreased motor activity, apathy and sleepiness
What is characteristic of hyperactive delirium?
Agitation, irritability, restlessness and aggression.
Hallucinations and delusions are prominent
Can be confused with functional psychoses
What are the causes of delirium?
‘HE IS NOT MAAD’ H= hypoxia E= endocrine (hyper/hypothyroidism, hyper/hypoglycaemia, cushings) I= infection S= stroke
N= nutritional (decrease in thiamine, decrease in nicotine acid, decrease in vitamin B12).
Others= sleep deprivation, sensory deprivation, relocation.
Theatre= anaesthetic, opiate analgesics, other post op complications.
Metabolic- electrolyte disturbance, hepatic or renal impairment
Abdominal= faecal impaction, malnutrition, urinary retention, bladder catheterisation
Alcohol= either intoxication or delirium tremens
Drugs= benzodiazepines, opioids, anticholinergics, anti parkinsonian meds, steroids
What are the risk factors for delirium?
Older age (>65) Sensory impairement Recent surgery Dementia Renal impairement Multiple co morbidities Physical frailty Male sex Previous episodes Severe illness- CCF
What examinations are done for delirium?
During or before history a thorough physical examination should be performed: A to E approach and conscious level should be assessed (AVPU/ GCS)
vital signs- O2 sats, pulse, blood pressure, temperature, capillary blood glucose
Nutritional and hydration status, CVS exam, respiratory exam, abdominal exam, neurological exam
What are the investigations done for delirium?
Bedside: . Urinalysis MC+S to look for UTI Bloods: . FBC . U and Es . LFTS . Calcium . TFTs . Glucose . B12 . Folate . Ferritin (nutritional deficiencies)
Infection screen: blood culture and urine culture
Imaging: CXR
Others you may carry out: ABG (hypoxia), CT head (head injury, intracranial bleed, CVA) and you may consider lumbar puncture, EEG
What diagnostic questionnaires can be used to diagnose delirium?
Abbreviated mental test (AMT)
Confusion Assessment method (CAM)
Mini mental state examination (MMSE)
What are the differential diagnoses for Delirium?
Dementia Mood disorders (depression or mania (bipolar)) Late onset schizophrenia Dissociative disorders Hypo or hyperthyroidism
What is the management of delirium?
. Treat the underlying cause
Any infection, laxatives for constipation, catheterisation for urinary retention, analgesia if required
. Reassurance and re-orientation
. Provide an appropriate environment (quiet well lit side room, consistency in care and staff, reassuring nursing staff, family members present, optimise sensory acuity etc…)
. Manage disturbed, violent or distressed behaviour
May give some haloperidol or onlanzapine
What is dementia?
A global impairment of cognitive function and personality without impairment of consciousness
What is the pathophysiology behind Alzheimer’s?
Cholinergic hypothesis- reduction in acetylcholine due to degeneration of cholinergic neurones
Tau hypothesis- phosphorylation of tau protein which causes neurofibrillary tangles
Amyloid hypothesis- formation of extracellular beta amyloid plaques
What are the microscopic and macroscopic changes in alzheimers dementia?
Microscopic: neurofibrillary tangles (tau proteins) and beta amyloid plaque formation
Macroscopic: cortical atrophy, widened Sulci, enlarged ventricles
What are the irreversible causes of dementia?
Irreversible... Alzheimer’s Fronto temporal Dementia with Lewy bodies Parkinsonian disease with dementia Huntingtons
Infections
Syphilis
CJD
Vascular- vascular dementia, multi infarct dementia, CVD
Traumatic head injury
