Old age psychiatry (dementia and delirium) Flashcards
Definition of delirium?
Delirium is an acute, transient, global organic disorder of CNS functioning resulting in impaired
consciousness and attention. There are different types of delirium: hypoactive, hyperactive and
mixed depending on the clinical presentation
Features of ageing
Most OA services start at age 65
A normal phase of life
- Cognitive changes
Reduced abilities versus accumulated wisdom
Physical changes
- Reduced function/complex needs versus positive adaptation
Social changes
- Loss and isolation versus freedom from responsibility
What are the cognitive and social changes that come with ageing?
Cognitive changes
Reduced cognitive ability, memory impairments, sometimes less agile thought processes. Wiser older adult + respected elder is found throughout various societies.
Physical changes
Complex needs! Multiple physical comorbidities. Sometimes able to adapt positively to this and requirement for adaptation, however. OA running groups/exercise etc
Social changes
- Loneliness big burden on OA populations. Loss of family members, social ties, friendships. No longer have to think about mortgages, looking after children, etc etc
Why do we need Older Adult services?
Differences in presentation
Differences in needs
Impact of (often deteriorating) physical health
- Causation/Differential Diagnosis
- Management
Impact of mental health condition
- Physical Health
- Suicide
Impact of physical health on old age psychiatry
Bidirectional relationship
- Physical illnesses as aetiological/risk factors
- Consequences of mental illness on physical health
Sensory Impairments are direct risk factors for MH problems
Considerations for treatment
↑body fat; ↓ body muscle; ↓ relative body water
↓ renal blood flow and function
Physical illnesses as risk factors – Diabetes, cardiac risk factors
Mental Health Problems as direct consequences of physical illnesses – stroke, thyroid disease, Parkinson’s Disease
Mental Health causing physical health problems
Through direct problem of MH problem, e.g. self-neglect
Through problems associated with treatment, e.g. lithium causing renal failure
74 year old man
BG: Type 2 Diabetes, Osteoarthritis,
CKD 3, Previous stroke
“I don’t know why I’m here, everything’s fine”
Clerking notes – fall at home
Examination – largely normal
Fall – tripped over his dog at home, pressed citywide alarm as couldn’t get himself up.
History – appropriate answers to all of the questions, but they’re very vague. Doesn’t remember the fall at home yesterday. Spends a lot of the conversation asking where his razor is and recurrently coming back to how he hasn’t been getting on with his son-in-law, as he’s moving things about the house.
Blood tests – normal
CT Head – no acute changes, no intracranial haemorrhage, stroke or space occupying lesion
Ring daughter
Mild confusion started 18m ago
Slowly getting more confused over this time
Remembers his childhood without any problems
Can’t tell her what he does with his day when she rings
Generally still very cheery and enjoys seeing family
What are the DDs?
Alzheimer’s Dementia
Lewy Body Dementia
Depression
Hypoactive Delirium
Causes of delirium
PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication/Metabolism
Environment/Electrolytes
Treatment for delirium
Recovery can take 3-6 months!
Treatment
Treat the cause
Supportive environment
May need benzodiazepines or antipsychotics
Features of Hypoactive (40%) delirium
Lethargy, dec motor activity, apathy and sleepiness
Most common type of delirium but often unrecognised
Can be confused with depression
Features of hyperactive (25%) delirium
Agitation, irritability, restlessness and aggression
Hallucinations and delusions prominent
Maybe confused with functional psychoses
Mixed (35%) delirium features
Both hypo- and hyperactive subtypes co-exist and therefore there are signs of both
Causes of delirium
HE IS NOT MAAD
Hypoxia - resp failure, MI, HF, PE
Endocrine - Hyper+Hypo T, hyper + hypoglycaemia, cushings
Infection - UTI, Pneumonia, encephalitis, meningitis
Stroke - Stroke, raised ICP, intercranial haemorrhage, space occupying lesions
Nutritional- Dec thiamine, nicotinic acid, vitamin B12
Others - pain, sensory deprivation, sleep deprivation
Theatre - Anaesthetic, opiate analgesics
Metabolic - Hypoxia, hyponatraemia, hep + renal impairment
Abdominal - faecal impaction, malnutrition, urinary retention
Alcohol
Drugs - benzos, opioids, anti-Parkinsonism, steroids
Most common cause of delirium
UTI
Epidemiology of delirium
Delirium occurs in about 15–20% of all
general admissions to hospital.
Delirium is the most common complication of hospitalization in the elderly population.
Up to two-thirds of delirium cases occur in inpatients with pre-existing dementia.
15% of >65s are delirious on admission to hospital.
RFs for delirium
Older age ≥65
Multiple co-morbidities
Dementia
Physical frailty
Renal impairment
Male sex
Sensory impairment
Previous episodes
Recent surgery
Severe illness (e.g. CCF)
Clinical features of Delirium
DELIRIUM
Disordered thinking: Slowed, irrational, incoherent thoughts.
Euphoric, fearful, depressed or angry.
Language impaired: Rambling speech, repetitive and disruptive.
Illusions, delusions (transient persecutory or delusions of misidentification) and
hallucinations (usually tactile or visual).
Reversal of sleep-wake pattern: i.e. may be tired during day and hyper-vigilant at night.
Inattention: Inability to focus, clouding of consciousness.
Unaware/disoriented: Disoriented to time, place or person.
Memory deficits.
ICD-10 criteria for the diagnosis of delirium
Impairment of consciousness and attention
Global disturbance in cognition
Psychomotor disturbance
Disturbance of sleep-wake cycle
Emotional disturbances.
Delirium Key facts
Sleep-wake cycle Disrupted
Attention Markedly reduced
Arousal Increased/decreased
Autonomic features Abnormal
Duration Hours to weeks
Delusions Fleeting
Course Fluctuating
Consciousness level Impaired
Hallucinations Common (especially visual)
Onset Acute/subacute
Psychomotor activity Usually abnormal
Dementia key facts
Sleep-wake cycle Usually normal
AttentionNormal/reduced
Arousal Usually normal
Autonomic featuresl Normal
Duration Months to years
Delusions Complex
Course Stable/slowly progressive
Consciousness level No impairment
Hallucinations Less common
Onset Chronic
Psychomotor activity Usually normal
Historical questions to ask in delirium
Much of the history may be collateral as obtaining the history from the patient may
prove very difficult.
Identify rate of onset and course of the confusion.
Any symptoms of underlying cause, e.g. symptoms of infection or of intracranial
pathology?
Having an understanding of their premorbid mental state is important.
Are they hypo-alert or hyper-alert?
Do they have hypersensitivity to sound and light?
Is there any perceptual disturbance (misidentification, illusions and
hallucinations)?
Take a thorough drug history and a full alcohol history
MSE for delirium
Appearance &
Behaviour
Hypo- or hyper-alert. Agitated, aggressive, purposeless
behaviour.
Speech Incoherent, rambling.
Mood Low mood, irritable or anxious. Mood is often labile.
Thought Confused, ideas of reference, delusions.
Perception Illusions, hallucinations (mainly visual), misinterpretations.
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Cognition Disoriented, impaired memory, reduced
concentration/attention.
Insight Poor
Investigations for delirium
Routine investigations: Urinalysis (UTI); Bloods: FBC (infection); U&Es
(electrolyte disturbance); LFTs (alcoholism, liver disease); calcium
(hypercalcaemia); glucose (hypo-/hyperglycaemia); CRP (infection/inflammation);
TFTs (hyperthyroidism); B12, folate, ferritin (nutritional deficiencies); ECG
(cardiac abnormalities, acute coronary syndrome); CXR (chest infection);
Infection screen: blood culture (sepsis) and urine culture (UTI).
2. Investigations based on history/examination: ABG (hypoxia), CT head (head
injury, intracranial bleed, CVA), and you may consider lumbar puncture
(meningitis), EEG (epilepsy).
3. Diagnostic questionnaire (helps with diagnosis but also monitoring):
Abbreviated Mental Test (AMT): A quick easy tool (see OSCE tips 3).
Confusion Assessment Method (CAM): Usually performed after AMT (see
OSCE tips 3).
Mini-Mental State Examination (MMSE)
Presentation of delirium
Sudden onset, different to usual self
Fluctuating course
Disorientation
Poor concentration, inattention
Poor STM
Abnormal perception; Hallucinations
Abnormalities of Sleep-wake cycle
Psychotic thoughts
Agitation
Emotionally labile
Delirium vs dementia
Look at slide 33 old age psychiatry
DDs of delirium?
Dementia.
Mood disorders: depression or mania (bipolar).
Late onset schizophrenia.
Dissociative disorders.
Hypothyroidism and hyperthyroidism (may mimic hypo- and hyperactive delirium
respectively).
Management of delirium
Person centred care
Identify and manage the possible underlying cause or combination of causes.
Ensure effective communication and reorientation
Supportive management of delirium
Clear communication – explain what you are doing slowly and clearly, remember their STM is impaired so they might not remember. Try to use questions that need a ‘yes or no’ rather than asking them questions that rely on their memory as this can be distressing.
Reminders of the day, time, location and identification of surrounding persons.
Have a clock available.
Have familiar objects from home, especially glasses, walking aids and hearing aids.
Staff consistency - both doctors and nurses. Try not to move beds/wards.
Involve the family and carers.
Remove catheters etc where possible.
Quiet environment with low lighting.
Uninterrupted sleep – do they really need obs overnight?
Mobilise regularly with physio – NICE recommends no cot side, encourage walking/motion exercises 3x daily
Questions for Abbreviated Mental Test
- Age? (1)
- Time to the nearest hour? (1)
- Recall address at end: ‘42 West Street’
(1) - ‘What year is it?’ (1)
- ‘Where are you right now?’ (1)
- Identify two people. (1)
- ‘What is your date of birth?’ (1)
- ‘Date of First World War?’ (1)
- ‘Who is the current monarch?’ (1)
- ‘Count backwards from 20 to 1.’ (1)
≥8 → cognitive impairment unlikely
Question for Confusion Assessment Method
The Confusion Assessment tool (CAM)
involves assessing a patient for four features.
The diagnosis involves the presence of 1 and
2 + either 3 or 4:
1. Acute onset and fluctuating course.
2. Inattention (e.g. using the serial 7s test
where 7 is subtracted from 100 and then
7 is taken from each remainder, i.e. 100,
93, 86, 79, 72…).
3. Disorganized thinking (e.g. incoherent
speech).
4. Alteration in consciousness.
Management of delirium
Treat underlying cause - Treat infections, correct electrolytes, stop potential offending drugs, Laxatives for faecal impaction
Reassurance and re-orientation
Provide appropriate environment - Quiet, well-lit side room, consistency in care and staff, reassuring nursing staff
Managing disturbed, violent or distressed behaviour - encourage oral intake and continence, verbal and non- verbal de-escalation, oral low dose haloperidol (0.5-4mg) or olanzapine (2.5-10mg), avoid benzos
What is not first line for delirium?
Antipsychotics and benzodiazepines are never first-line for managing delirium and
unfortunately this is a misconception amongst many clinicians. Treating the underlying cause,
providing reassurance and re-orientation and an appropriate environment are the main means
for treating delirium as recommended by NICE guidelines. Low dose antipsychotics should only be used as a last resort in cases of violent or severely distressed behaviour and when
other ways of calming the patient have failed.
What are the outcomes of delirium
Full recovery 18-22%
Functional impairment
Increased costs
Institutionalization
Death 30-40%
Prolonged hospitalisation
Psychological stress
Long term cognitive impairment
What is the definition of dementia?
Dementia is a syndrome of generalized decline of memory, intellect and personality, without
impairment of consciousness, leading to functional impairment.
What are the irreversible causes of dementia?
Neurodegenerative: Alzheimer’s disease, frontotemporal dementia, Pick’s disease, dementia with
Lewy bodies (DLB), Parkinson’s disease with
dementia, Huntington’s disease.
Infections: HIV, encephalitis, syphilis, CJD.
Toxins: Alcohol, barbiturates, benzodiazepines.
Vascular: Vascular dementia, multi-infarct
dementia, CVD.
Traumatic head injury
What are the reversible causes of dementia?
Neurological: Normal
pressure hydrocephalus,
intracranial tumours,
chronic subdural
haematoma.
Vitamin deficiencies:
B12, folic acid, thiamine,
nicotinic acid (pellagra).
Endocrine: Cushing’s
syndrome,
hypothyroidism.
How can we diagnose dementia?
Clinical Syndrome
Exclude Differential Diagnoses
Bloods (confusion screen)
Imaging
CT/MRI
DaT/SPECT
Formal cognitive testing
- ACE-III
What is ACE-III?
Assess 5 cognitive domains
“Normal” score 82/100
Sub-scores just as imporant as total score
Change in score is relevant over time
“Normal” score doesn’t exclude dementia
What are the ACE-III Domains/Sub-scores
Attention /18
Memory /26
Fluency /14
Language /26
Visuospatial /16
A useful mnemonic for reversible/ preventable causes of dementia?
DEMENTIA
Drugs (e.g. barbiturates), Eyes and Ears (visual/hearing impairment may be confused
with dementia), Metabolic (Cushing’s, hypothyroidism), Emotional (depression can
present as a pseudodementia), Nutritional deficiencies/Normal pressure hydrocephalus,
Tumours/Trauma, Infections (e.g. encephalitis), Alcoholism/Atherosclerosis
Most prevalent dementia’s
Alzheimer’s (50%)
Vascular dementia (25%)
Lewy Body dementia (15%)
Fronto-temporal dementia (<5%)
Other causes of dementia (<5%)
What is the pathophysiology of Alzeheimers?
In Alzheimer’s disease there is degeneration of cholinergic neurons in the nucleus basalis of
Meynert leading to a deficiency of acetylcholine. Other pathophysiological changes can be
divided into microscopic (Fig. 10.2.3) and macroscopic:
Microscopic → Neurofibrillary tangles (intracellularly) and β-amyloid plaque formation
(extracellularly).
Macroscopic → Cortical atrophy (commonly hippocampal). Widened sulci and enlarged
ventricles.
