Old Age Psychiatry Flashcards
What is delirium?
An acute, transient, global organic disorder of CNS functioning resulting in impaired consciousness and attention.
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 is the ICD-10 criteria for the diagnosis of delirium?
Impairement of consciousness and attention Global disturbance in cognition Psychomotor disturbance Disturbance of the sleep wake cycle Emotional disturbances
(Other features include- disordered thinking, euphoric, fearful, depressed, angry, language impaired, illusions, delusions, hallucinations, reversal of the sleep- wake pattern (tired during day, hyper vigilant at night), inattention, unaware/disorientated, memory deficits).
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 syndrome of generalised decline of memory, intellect and personality without impairment of consciousness, leading to functional impairment.
What is the pathophysiology behind Alzheimer’s?
Degeneration of cholinergic neurones in the nucleus basalis of meynert, leading to a deficiency in acetylcholine.
What are the microscopic and macroscopic changes in dementia?
Microscopic: neurofibrillary tangles and beta amyloid plaque formation
Macroscopic: cortical atrophy, widened Sulci, enlarged ventricles
