OP: Dementia + Delerium Flashcards
What is delirium?
Acute, transient and reversible state of confusion ( global disorder of cognition and consciousness). often due to other cause (infection, drugs, dehydration).
Onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.
What 2 states of delirium can you get?
HYPOactive
HYPERactive
what are clinical features of hypoactive delirium?
(often confused with depression)
Lethargy
withdrawn
Inattention
Slowness with everyday tasks
Excessive sleeping
what are clinical features of hyperactive delirium?
Agitation
Delusions
Hallucinations
Wandering
Aggression
Patients CAN fluctuate between hypoactive and hyperactive delirium - TRUE OR FALSE?
TRUE
Causes of delirium? CHIMPS PHONED
Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic / renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)
Assessing the confused patient:
in medical notes look for relevant past medical history such as…
Previous episodes of confusion
head injury
recent admission
stroke
atherosclerosis
Assessing the confused patient:
in medical notes look for current medications….
review drugs that may cause / contribute to confusion
e.g. opiates
anticholinergics
benzodiazepams
steroids
Antihistamines
antipsychotics
antidepressants
parkinson drugs
Assessing the confused patient:
in medical notes look for social Hx….
Home situation - carers / live alone
evidence of how coping
excess alcohol
excessive drug use
What bloods do you need to request for a confusion screen for your patient? And what looking for?
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g.
hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?
most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.
Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture
What questions does the Abbreviated Mental Test Score (AMTS) ask?
Ask the patient:
- “What is your age?”
- “What is the time to the nearest hour?”
- Give the patient an address, and ask them to repeat it at the end of the test (e.g. “42 West Street”)
- “What is the year?”
- “What is the name of this place?” or “What is your house number?”
- Can the patient recognise two persons (e.g. doctor, nurse)?
- “What is your date of birth?” (day and month sufficient)
- “In what year did World War 1 begin?”
- “Name the present monarch/prime minister/president”
- “Count backwards from 20 down to 1”
Each questions answered CORRECTLY. gets 1 point.
SCORE OF 6 or less suggests DEMENTIA ? DELIRIUM - further tests to confirm which
What would you look for in clinical examination of someone you are assessing for delirium?
Vital signs (e.g. fever in infection, low SpO2 in pneumonia)
Level of consciousness (e.g. GCS/AVPU)
Evidence of head trauma
Sources of infection (e.g. suprapubic tenderness in urinary tract infection)
Asterixis (e.g. uraemia/encephalopathy)
There is a patient with suspected delirium- you are asked to do a confusion screen.
What 3 categories of investigation does this involve?
Bloods
Urinanalysis
Imaging
What bloods do you need to request for a confusion screen for your patient? And what looking for?
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g.
hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?
most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.
Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture
What imaging do you need to do for a confusion screen for your patient? What looking for?
CT head- intracranial pathology (bleeding, ischaemic stroke, abscess)
Chest X-ray - pneumonia, pulmonary oedema
What is definitive management of delirium?
treat underlying cause
Supportive management of delirium?
- Pt has access to aids e.g. hearing aids/ glasses/ walking stick
- encourage independent activities e.g. washing / eating/ toileting
Environmental management of delirium?
- Access to clock and other orientation reminders
-familiar obects - photos/ wear own clothes
- involve family / regular carers
- ensure lighting and temperature optimal
Why must be very careful in treating an elderly patient for delirium when they have a background of Parkinsons / Lewy Body dementia?
Haloperidol 0.5 mg is the 1st-line sedative (oral preferred or IM if refused to take + immediate threat to others)
Parkinson’s disease- antipsychotics can worsen symptoms
1. Reduce Parkinson meds
2. if urgent treatment - use atypical antipsychotics e..g clozapine
What score can we use in a clinical setting to evaluate for frailty?
Rockwood clinical frailty score >65yrs
Some steps to prevent delirium?
avoid drugs that cause: opiates / benzodiazepines
asses factors that cause: pain control / drugs
Identify those at risk and monitor
use supportive and environmental management approaches for all patients
Define capacity
The ability to 1) understand, 2) retain, 3) weigh up information and 4) communicate a decision
When assessing capacity, what assumption should you start with?
Always start with the assumption that the patient DOES have capacity.
What steps are taken in assessing capacity?
- Maximise capacity - i.e. start from the presumption that patient has capacity to make decision. Offer audio/written information. Have family/friends present to help communicate. Discuss options in a way that they remember
Still unsure if pt has capacity? Move to step 2.
- Assess capacity - can they understand? Retain?
Weigh up info? Communicate decision?
If not - need advanced decisions as pt may lack capacity.
- Next - Is there an advance decision to refuse treatment (always present in England).? Has someone else been given legal authority to make decision?
If yes, that makes decision. If not, you make decision. - Reach agreement with team about treatment and care.
Characteristic pathological feature of Lewi-Body dementia?
alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
Features of Lewy-Body dementia?
Progressive cognitive impairment
Parkinsonism
Visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
Difference in features of Alzehimers and Lewy-Body
Lewy body- progressive cognitive impairment
Alzheimers- early impairment in attention/memory and executive function rather than just memory loss and cognition may be fluctuating
Diagnosis of Lewy body dementia?
Usually clinical
Increasing use of single-photon emission computed tomography (SPECT)
The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%
Management of Lewy body dementia?
both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s
Drug to avoid in Lewy body dementia and why?
neuroleptics should be avoided in Lewy body dementia–>patients are extremely sensitive and may develop irreversible parkinsonism.
Pathophysiology of Alzheimers?
cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
Name a NMDA receptor antagonist?
Memantine
Memantine indications?
Alzheimers
Lewy body dementia
What features make delirium a more likely diagnosis than dementia? (Pass Med)
Fluctuating symptoms e.g. worse at night, then normal
Impairment of consciousness (dementia does not see this until very late on)
Abnormal perception (e.g. illusions and hallucinations)
Agitation, fear
Delusions
If of the main factors of delirium is impairment of consciousness, how would you evaluate for this in your in your patient?
Reduced score on the Glasgow coma scale e.g. 12/ 15
often accompanied with psychotic symptoms
Why must be very careful in treating an elderly patient for delirium when they have a background of Parkinsons / Lewy Body dementia?
Haloperidol 0.5 mg is the 1st-line sedative
Parkinson’s disease- antipsychotics can worsen symptoms
1. Reduce Parkinson meds
2. if urgent treatment - use atypical antipsychotics e..g clozapine
What given for patient with delirium when Haloperidol contraindicated? Why would it be?
Low-dose lorazepam if haloperidol is contraindicated (atpical)
for people with Parkinson’s disease, Lewy-body dementia, or prolonged QT interval
What is delirium?
Acute confusional state, sudden onset and fluctuating state
How long does delirium develop over?
1-2 days
How can you recognise delirium?
Change in consciousness either hyper or hypo alert and inattention
What is delirium an indication of?
Frailty
What is delirium associated with?
Increased mortality
prolonged hospital admission,
higher complication rates
institutionalisation and increased risk of developing dementia
What is the resolution of delirium like?
It takes a while to resolve and can take up to 3 months to get back to normal level of functioning.
Some people may never return to their baseline
What cognitive assessment tool could you use for a pt with suspected dementia ?
NICE -lots
e.g 6-point `Cognitive impairment test (6-CIT)
- temporal orientation
- address recall
- count back from 20
- months of the year in reverse
Score 0-7 out of 28 = normal
8 or more out of 28 = significant
Oxford clinical med book says AMTS and Mental state examination
What are some reversible causes of dementia you might find on investigation (bloods)
high TSH - hypothyroidism
Low B12
Low folate
low thiamine (alcohol)
low Ca
What bloods would you order for pt with dementia ?
FBC
ESR / CRP
U&E
Ca
HbA1c
LFT
TFT
serum B12/folate
What bedside investigations might you do for dementia patient?
urine microscopy and culture (if indicated)
ECG
What imaging might you order for dementia pt?
MRI / CT - rule out subdural haematoma / normal pressure hydrocephalus
CXR - infection
EEG - suspect delirium, front temporal dementia, CJD, seizure
Define dementia
Dementia is irreversible, progressive decline and impairment of more than one aspect of higher brain function (concentration, memory, language, personality, emotion).
This occurs without impairment of consciousness.
What is the most common type of dementia in UK
Alzheimer’s dementia
What histological finding is seen in Alzheimer’s?
amyloid plaques (clumps of beta-amyloid) and neurofibrillary tangles ( tau protein).
What are the clincial features of Alzeimer’s?
Progressive global cognitive loss (can affect all areas of brain)
most common is memory loss. Executive function loss (planning / reasoning)
speech
visuo-spatial skill: orientation.
RF for Alzheimers
1st degree relative
Downs syndrome
loneliness (living alone)
low physical activity
smoking
Vascular (high BP, DM, dyslipidaemia, AF)
Management of Alzheimers?
Acetylcholinesterase Inhibitors - Rivastigmine
Memantine - NMDA antagonist for severe disease / AChE not tolerated
How common is vascular dementia?
2nd most common type
What are some RF for vascular dementia
9x risk if had a stroke
hypertension
smoking
diabetes
hyperlipidaemia
obesity
hypercholesterolaemia
What happens in vascular dementia and how does it progress?
multiple small cerebrovascular infarcts
stepwise progression - stable period and then acute deterioration
What are the clinical features of vascular dementia?
cognitive impairment following event
mood disorders - psychosis, delusions, hallucinations and paranoia
Seizures
Memory disturbance
Gait/speech/emotional disturbance
Attention difficulty
Visual / motor symptoms
What do you find histologically in Lewy body dementia?
Spherical Lewy body proteins (alpha-synuclein) are deposited in the brain.
Lewy body proteins deposited mainly in substantia nigra in Parkinson’s disease.
What are the clinical features of Lewy body dementia
Fluctuating cognitive impairment
detailed visual hallucinations
later Parkinsonism develops
problems with complex tasks and sleep disorders common
What happens to brain in fronto-temporal dementia?
Frontal and temporal atrophy with loss of spindle neurons
What are the clinical feature of fronto-temporal dementia?
executive impairment
behavioural changes- disinhibition
emotional apathy
inability to recognise faces/objects
speech takes effort / not fluent
What are some differencials for dementia?
HIV related dementia
Normal pressure hydrocephalus
Creutzfeldt-Jakob disease
Severe depression
What medications can impair cognition and look like dementia
Anticholinergics
sedatives - benzodiazepams
opioids
corticosteroids
