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
What is orbitofrontal syndrome?
Disinhibition, aggressive and inappropriate behaviour, obsessive or repetitive stereotyped behaviours, euphoria, emotional lability, poor insight.
What is dorsolateral prefrontal syndrome?
Apathy, irritability, lack of ability to plan or sequence behaviour, decreased fluency, impaired abstraction.
What deficits can you get in the temporal lobe?
Dominant (left) temporal lobe
Non-dominant (right) temporal lobe
Bilateral disease
What does a dominant temporal lobe deficit cause?
Verbal agnosia, visual agnosia, receptive aphasia, hallucinations.
What does a non-dominant temporal lobe deficit cause?
Visuospatial deficiencies, inability to recognise faces (prosopagnosia), hallucinations
What does bilateral disease of the temporal lobe cause?
Blunted emotional reactivity, apathy, Korsakov syndrome, Kluver-Bucy syndrome (rare syndrome consisting of hyperorality and hypersexuality)
What deficits can you develop in the parietal lobe?
Dominant (left) parietal lobe
Non-dominant (right) parietal lobe
Bilateral disease
What does a deficit in the dominant parietal lobe cause?
Receptive aphasia, agnosia, apraxia, Gerstmann syndrome (finger agnosia, dyscalculia, dysgraphia, left-right disorientation)
What does a deficit in the non-dominant parietal cause?
Body hemineglect, visuospatial difficulties, anosognosia or denial of deficits, constructional apraxia
What does bilateral disease of the parietal lobe cause?
Visuospatial imperception, spatial disorientation, Balint syndrome (a rare disorder of visuo-spatial processing)
What does a deficit in the occipital lobe cause?
Visual perception defects such as visual agnosia, alexia and prosopagnosia, progressing to cortical blindness, Illusions and visual hallucinations Anton syndrome (a form of anosognosia involving the denial of cortical blindness)
What are the principal primary dementias?
Azlheimer’s disease
Lewy body dementia
Frontotemporal dementias
Huntington’s disease
What are the commonest dementias?
Alzheimer’s disease
Lewy body dementia
Vascular dementia
Frontotemporal dementia
What are the secondary dementias?
Vascular (infarction, vascular disease)
Infective (AIDS, neurosyphilis, Lyme disease)
Inflammatory (SLE, cranial arteritis, encephalopathy)
Neoplastic (primary or secondary tumour)
Endocrine (Hyper-hypo para/thyroidism, Cushing’s)
Metabolic (Cardiac, hepatic, and renal failure, anaemia)
Toxic (Alcohol, heavy metals, organic solvents)
Traumatic (Severe head injury, subdural haematoma)
Other (Normal pressure hydrocephalus, radiation)
What is the commonest cause of dementia?
Alzheimer’s, 50% of all cases
What are the risk factors for alzheimer’s disease?
Age (up to about 90) Female sex (female to male ratio is about 2:1) Family history Down's syndrome Head injury
What is the neuropathology of alzheimer’s disease?
Selective neuronal and synaptic loss leads to neurochemical abnormalities (cholinergic deficit) and symmetrical cortical atrophy (more pronounced in temporal and parietal lobes)
Extracellular senile plaques and intracellular neurofibrillary tangles are more common.
What are the clinical features of alzheimer’s disease?
Characterised by insidious onset and progression of memory loss and personality changes.
How common is Lewy body dementia?
Second most common dementia (20% of all cases)
What are the clinical features of Lewy body dementia?
Marked fluctuations in alertness and cognitive impairment
Vivid visual hallucinations and other psychotic symptoms
Early parkinsonism and neuroleptic sensitivity
Frequent faints and falls
What is the archetypal form of frontotemporal dementia and how common is it?
Pick’s disease (5% of all cases)
More common in females
What is the neuropathology of Pick’s disease?
Selective, often asymmetrical ‘knife-blade’ atrophy, neuronal loss, and gliosis affecting the frontal and temporal lobes.
Characteristic ‘ballooned’ neurons called Pick cells and tau-positive neuronal inclusions called Pick bodies.
What are the clinical features of Pick’s disease?
Insidious and progressive dementia Early and prominent personality changes and behavioural disturbances Eating disturbances Mood changes Cognitive impairment Language abnormalities Motor signs
What is the prevalence of Huntington’s disease and what is the mean age of onset?
5-10 per 100,000 in Caucasians
Onset usually in the 4th or 5th decade
What is the aetiology of Huntington’s disease?
Autosomal dominant disorder
Manifests in the presence of 36 or more glutamine-encoding CAG trinucleotide repeats in the huntingtin gene on chromosome 4.
What is the neuropathology of Huntingtons disease?
Abnormal huntingtin protein leads to degeneration of neurones, in caudate nucleus, putamen and cerebral cortex
Degeneration in the caudate nucleus and putamen is associated with movement disorders
Degeneration in the cerebral cortex is associated with dementia.
What are the clinical features of Huntingtons disease?
Choreiform (dance-like) movements
Progressive dementia
How common is vascular dementia?
Third commonest cause of dementia, accounts for about 20% of dementias.
What are the risk factors for vascular dementia?
Older age Male sex Cardiovascular disease Cerebrovascular disease Valvular heart disease Hypercoagulation disorders Hypertension Hypercholesterolaemia Diabetes Smoking Alcohol misuse
What is the neuropathology of vascular dementia?
Focal and diffuse disease often co-exist.
Focal disease may result from single or, more commonly, multiple thrombotic or embolic infarcts.
Diffuse disease (Binswanger disease and lacunar state), on the other hand, results from small vessel disease.
What are the clinical features of vascular dementia?
Classically has an abrupt onset and step-wise progression. Features vary according to the location of the infarcts.
Mood and behavioural changes are common.
Insight usually retained until late.
What are some other forms of dementias and amnestic syndromes?
Normal pressure hydrocephalus
HIV-related dementia
Creutzfeldt-Jakob disease and other prion-related diseases
Amnestic syndrome
What are the differential diagnoses for dementia?
Mild cognitive impairment Amnestic syndrome Delirium (can be superimposed upon dementia) Depressive disorder Late-onset schizophrenia (paraphrenia) Intellectual disability Substance misuse Iatrogenic causes, particularly drugs Dissociative disorder
What drugs can you give to help treat dementia?
Cholinesterase inhibitors (donepezil, rivastigmine, and galantamine.) Memantine (NMDA) receptor antagonist Other drugs to offset cognitive or functional decline include antioxidants (vitamin E)
What is the aim of management for dementia?
Secondary dementias may be partially reversed if the underlying cause can identified and treated.
Aim of management is to improve or maintain the quality of life of patient and carers by treating symptoms and complications of the dementia, addressing functional and social problems, and providing carers with education and support.
