sometimes called 'acute confusional state common clinical syndrome characterised by disturbed consciousness, cognitive function or perception Has an acute onset and fluctuating course. It usually develops over 1–2 days. It is a serious condition that is associated with poor outcomes. However, it can be prevented and treated if dealt with urgently.

Range of cognitive and behavioural symptoms that can include memory loss, problems with reasoning and communication and change in personality And a reduction in a person's ability to carry out daily activities, such as shopping, washing, dressing and cooking.

1. Alertness 2. AMT4 - age, DOB, place, current year 3. Attention - months of year backwards 4. Acute change or fluctuating course 4 and above = ?delirium +/- cognitive impairment 1-3 = possible cognitive impairment 0 = unlikely

OPMH Teaching (ppt as missed) Flashcards by Ella Harris

Define delirium

sometimes called ‘acute confusional state
common clinical syndrome characterised by disturbed consciousness, cognitive function or perception
Has an acute onset and fluctuating course.
It usually develops over 1–2days.
It is a serious condition that is associated with poor outcomes. However, it can be prevented and treated if dealt with urgently.

How well did you know this?

Not at all

Perfectly

Signs/symptoms of delirium

Impaired consciousness and attention
Rapid onset
Psychotic symptoms; usually visual hallucinations, transient delusions
Disturbance of the sleep–wake cycle
Emotional disturbance - depression, anxiety perplexity
Disturbance of motor activity - both under and over-activity.

How well did you know this?

Not at all

Perfectly

When does delirium often occur?

General medical wards
After hip fracture
After stroke

How well did you know this?

Not at all

Perfectly

Three types of delirium

Hyperactive - heightened arousal, restless, agitated and aggressive (least common)
Hypoactive - withdrawn, quiet and sleepy, underdiagnosed and misdiagnosed as depression. Longer hospital stay in this variant
Mixed

How well did you know this?

Not at all

Perfectly

Other 3 types of delirium

Delirium superimposed on dementia - common as dementia is strong RF
Persistent - several weeks-months
Subsyndromal delirium (SSD) - one or more but not all symptoms of delirium. Associated with lower cognitive function, increased hospital stay and decreased post discharge survival at 12 months

How well did you know this?

Not at all

Perfectly

Define dementia

Range of cognitive and behavioural symptoms that can include memory loss, problems with reasoning and communication and change in personality
And a reduction in a person’s ability to carry out daily activities, such as shopping, washing, dressing and cooking.

How well did you know this?

Not at all

Perfectly

ICD 10 dementia diagnosis features

6 months or more.
A decline in memory.
A decline in other cognitive abilities.
Preserved awareness of the environment (i.e. absence of clouding of consciousness).
A decline in emotional control, motivation or changes in social behaviour.

How well did you know this?

Not at all

Perfectly

Alzheimers disease - parietotemporal features

Aphasia
Agnosia
Apraxia
Apathy

How well did you know this?

Not at all

Perfectly

Frontal Alzheimers disease symptoms

Irritability
Disinhibition

How well did you know this?

Not at all

Perfectly

Scoring vascular dementia

Hachinski ischaemic score 1974

How well did you know this?

Not at all

Perfectly

Hachinski ischaemic score

Abrupt onset (2)
Stepwise deterioration (1)
Fluctuating (2)
Nocturnal confusion (1)
Preserved personality (1)
Depression (1)
Somatic complaints (1) - excessive thoughts about symptoms eg pain
Emotional incontinence (1)
RF for vascular disease (eg hypertension(1), stroke(2), atherosclerosis(1))
Focal neurological symptoms (2) or signs (2)

Score of 4 = AD or other dementia (non vascular)
Score of 7.= VaD

How well did you know this?

Not at all

Perfectly

Dementia with Lewy Bodies core features - two needed for probable diagnosis, one needed for possible

A. Fluctuating cognition with pronounced variations in attention and alertness.
B. Recurrent visual hallucinations which are typically well- formed and detailed.
C. Spontaneous motor features of parkinsonism.

How well did you know this?

Not at all

Perfectly

Supportive features of Lewy Body dementia

Repeated falls
Syncope
Transient LOC
Neuroleptic sensitivity
Systematized delusions
Hallucinations in other modalities

How well did you know this?

Not at all

Perfectly

Investigations for someone presenting with mood disturbance

Routine bloods - FBC, LFT, U&E, glucose, lipids, B12, folate, calcium, phosphate, magnesium
Urine dip for blood
ECG
CXR
CT head

How well did you know this?

Not at all

Perfectly

Confusion assessment method (CAM) for delirium

Acute onset and fluctuating
Inattention
Disorganised thinking
Altered level of consciousness

If features 1 and 2 and either 3 OR 4 are present = CAM positive

How well did you know this?

Not at all

Perfectly

4AT for delirium

Alertness
AMT4 - age, DOB, place, current year
Attention - months of year backwards
Acute change or fluctuating course

4 and above = ?delirium +/- cognitive impairment
1-3 = possible cognitive impairment
0 = unlikely

How well did you know this?

Not at all

Perfectly

What does NICE recommend as cognitive testing?

10 point cognitive screener (10-CS)
6 item cognitive impairment test (6CIT)
6 item screener
Memory impairment screen (MIS)
Mini-cog
Test your memory (TYM)

Questionaires for supplementing cognitive assessments

IQCODE - informant questionaire on cognitive decline in elderly - from someone who knows them well
FAQ - functional activities questionaire

MMSE biases

Baseline education level –> ceiling and floor effect
Language
Cultural barriers

Cut off for MMSE

Total is out of 30
<24 = cut off

Addenbrookes cognitive examination (ACE)

Total /100
MMSE + executive function, viuospatial, complex language
5 domains - attention, memory, verbal fluency, language and visuospatial abilities
Cut offs are <88 or <82

MOCA

30 points
Orientation, memory, language, attention, executive function
10 minutes
Detects early AD and mild cognitive impairment
Cut off <26

Other scales for cognition/dementia

Mattis Dementia rating scale
Cambridge cognitive examination revised (CAM-COG)
Azheimers disease assessment scale (ADAS-Cog)
FAB - frontal assessment battery

Abbey pain scale for dementia patients

Vocalisation
Facial expression
Body language
Physiological changes
Physical changes
Marking is 0-3+

Non-pharmacological (environment) measures do's and don'ts for delirium

Management of delirium caused by substance withdrawal or seizures

* Benzodiazepines * BUT do not used for non-withdrawal delirium

Antipsychotics for delirium

* Avoid in those with dementia + Lewy bodies and parkinsons * Limit to use in severe behavioural disturbance that place or others are at risk and non-pharm have failed

Antipsychotics for delirium examples

* Haloperidol or Olanzapine for short term (<1 week)

follow up for delirium

* Refer to memory service or CMHT for older people for further assessment and f/u * Could be first presentation of dementia or severe illness * Consider support and counselling

What to do if patient lacks capacity?

* Treat in their best interests under mental capacity act (MCA) * Or in some cases mental health act (MHA)

Menta capacity act principles

1. Presume capacity 2. Individuals being supported to make their own decisions 3. Can be an unwise decision 4. Best interests 5. Least restrictive option

2 part test of capacity

* Diagnostic - impairment of functioning of the brain/mind * Capacity - understand, retain, weigh-up, communicate back

DOLS - deprivation of liberty safeguards

* Part of MCA * Ensure people in care homes and hopsitals are looked after in a way that does not inappropriately restrict freedom * Must follow process if they believe it is in their best interests to deprive a person of their liberty in order to provide a care plan

MHA vs MCA

* MHA does not cover treating physical illness * Unless cause or direct consequence of MH illness * Delirium may need to be detained under MHA for period of assessment and treatment

Commonly used sections of mental health act

* Nurses holding power for up to 6 hrs on a patient already in hospital informally being treated for mental disorder * Not renewable - period of assessment/detention cannot be restarted/renewed * No right to appeal to tribunal * Cannot be used in A&E * Drs holding power of 73hrs for a full MHA assessment

Police holding power MHA

* Allows for individual to be detained for up to max period of 24hrs * Clock starts ticking when an individual arrives at a place of safety

Management of dementia - general

Bio, psycho, social Biological: * optimise vascular RF * possible role Ach esterase inhibitors for AD +/- memantine * Treat any psych co-morbid (eg SSRI) * Advice re alcohol Psychological: * Cognitive stimulation therapy * CBT depression * Living well with dementia * Reality orientation, reminiscence therapy Social: * Ensuring social support - carers, meals on wheels, day centre * Compliance aids for meds * OT assessment * Alzheimers society - info and carer assessment * Support for carers - carers groups etc

Ach esterase inhibitors available for AD

* Donepezil * Galantine * Rivastigmine Stopped if no improvement after 3-4 months

Side effects of Ach esterase inhibitors for AD

* Headache * Nausea + vomotting * Weight loss * Diarrhoea * Anorexia

When is memantine used?

* Moderate to severe Alzheimers * If unable to tolerate Ach esterase inhibitors * NMDA antagonist - affects glutamate transmisison

Risk assessment for those with dementia

* Ask about situations where the patients have put themselves at risk and how often this has happened * Eg getting locked out of house, getting lost, driving, leaving cooker on

Management depression

* Biopsychosocial * Antidepressants * Psychological - CBT, psychotherapy * Social - social prescribing