Organic disorders (delirium and dementias) - Burton Flashcards
What is delirium and what is its prevalence of in-patients in the over 65s?
An aetiologically non-specific syndrome characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake cycle (that is) transient and of fluctuating intensity.
Affects 40%
What are the clinical features of delirium?
Impairment of consciousness and difficulty focusing, maintaining, and shifting attention
Impairment of abstract thinking and comprehension, and, in some cases, transient delusions
Impairment of immediate recall and recent memory, with remote memory relatively spared
Disorientation in time and, in severe cases, also in place and person
Perceptual abnormalities and, in severe cases, also in place and person
Perceptual abnormalities including distortions, illusions, and hallucinations, most commonly in the visual modality
Hyperactivity or hypoactivity, and sudden shifts from one to the other
Disturbance and, in severe cases, reversal of the sleep wake cycle
Emotional disturbances and lability
What is an easier way to remember delirium symptoms? (DELIRIUM)
Disordered thinking Euphoria, angry, fearful Language impairment Illusions/delusions/hallucinations Reversal of sleep wake cycle Inattention Unaware/disorientated Memory deficit
What are the differential diagnoses for delirium?
Dementia Delirium superimposed upon dementia Substance misuse Affective disorder Psychotic disorder
What are the main differences between delirium and dementia?
1st column delirium - 2nd column dementia
Onset: Rapid - Fluctuating
Course: Fluctuating - Progressive
Duration: Days/weeks - Months/years
Consciousness: Altered - Clear
Attention: Impaired - Usually normal
Memory: Immediate recall impaired - immediate recall usually normal
Psychomotor changes: Hyperactivity or hypoactivity - usually none
Sleep-wake cycle: Disturbed - often normal
What are the causes of delirium? (PINCH ME WHIMP)
Pain Infection/Intoxication Nutrition (lack of adequate) Constipation Hydration/Hypoxia Medication- Antihistamines, Steroids, Antispasmodics, Opiates, L-Dopa, Anticonvulsants, Sedatives, Recreational. Environmental
Wernicke's encephalopathy Hypertensive encephalopathy Intracranial haemorrhage Meningitis/encephalitis Poisoning
What are the minimum investigations and further ones you should also do?
Minimum: FBC, U&Es, urinary dipstick, MSU, CXR, ECG
Further:
Bloods: LFTs, TFTs, glucose, thiamine level, drug screen
Infection screen: Sputum samples, blood cultures, lumber puncture
Imaging, AXR, CT head, MRI head
Other: EEG, urinary drug screen
What precautions can be taken in vulnerable patients to avoid delirium?
Regular cognitive assessments
Rationalising the drug chart
Sensory aids and hearing aids are available
Fluids and nutrition, correcting electrolyte imbalances and nutritional deficiencies
Gentle mobilisation
Relatives and carers to spend time at the bedside
How should you treat an agitated or psychotic patient with delirium?
Haloperidol (1st choice)
Keep dose to a minimum (0.5mg QDS)
What are some complications of delirium?
Prolonged hospital stay Accelerated cognitive decline Aspiration pneumonia Fluid and electrolyte imbalance Malnutrition Falls/Injuries Decreased mobiliy Pressure sores
What is the estimated one-year mortality following discharge from a case of delirium?
50%
What is the estimated one-year mortality in hospital and following discharge of delirium?
50%
What is the definition of dementia?
A syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement.
Consciousness is not clouded.
How do you diagnose dementia?
The primary requirement for diagnosis is evidence of a decline in both memory and thinking sufficient to impair personal activities of daily living, as described above.
The impairment of memory typically affects the registration, storage, and retrieval of new information, but previously learnt and familiar material may also be lost, particularly in later stages.
Type is determined on clinical grounds, and the diagnosis can only be verified by brain biopsy or at post-mortem. (Cannot be verified)
What are the 7 clinical features of dementia?
- Memory loss
- Impaired thinking
- Language impairments
- Deterioration in personal functioning
- Disturbed personality and behaviour
- Perceptual abnormalities
- Motor impairments
Elaborate on this feature of dementia: memory loss.
Short-term memory is more affected than long-term memory, with impaired learning and disorientation
(First in time and then in place and person)
Elaborate on this feature of dementia: impaired thinking.
Poor judgement
Decreased fluency
Dyscalculia
Concrete thinking and impaired abstraction
Lack of ability to plan or sequence behaviour
Delusions
Elaborate on this feature of dementia: language impairments.
Expressive and receptive dysphasia/aphasia
Elaborate on this feature of dementia: deterioration in personal functioning.
Deterioration in occupational and social functioning and self-care.
Severe senile self-neglect is referred to as Diogenes syndrome, which may be accompanied by syllogomania, a tendency to hoard rubbish.
Elaborate on this feature of dementia: disturbed personality and behaviour.
Euphoria and emotional lability or apathy and irritability
Disinhibition leading to aggressive or inappropriate behaviour
Inattention and distractibility
Obsessive stereotyped behaviours
Elaborate on this feature of dementia: perceptual abnormalities?
Visual and auditory agnosia Visuospatial difficulties Body hemi-neglect Inability to recognise faces (prosopagnosia) Illusions Hallucinations Cortical blindness
What deficits can you get in the frontal lobe?
Orbitofrontal syndrome
Dorsolateral prefrontal syndrome
