OPMH Teaching (ppt as missed) Flashcards
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.
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.
When does delirium often occur?
- General medical wards
- After hip fracture
- After stroke
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- Hypoactive - withdrawn, quiet and sleepy, underdiagnosed and misdiagnosed as depression.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
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
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.
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.
Alzheimers disease - parietotemporal features
- Aphasia
- Agnosia
- Apraxia
- Apathy
Frontal Alzheimers disease symptoms
- Irritability
- Disinhibition
Scoring vascular dementia
Hachinski ischaemic score 1974
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
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.
Supportive features of Lewy Body dementia
- Repeated falls
- Syncope
- Transient LOC
- Neuroleptic sensitivity
- Systematized delusions
- Hallucinations in other modalities
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
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
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
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
- Presume capacity
- Individuals being supported to make their own decisions
- Can be an unwise decision
- Best interests
- 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
