P-2 Flashcards
Potential Delirium Contributing Drugs
- TCAs
- Anticholinergic (-amine)
- Benzodiazepines
- Corticosteroids
- H2 Receptor Antagonists (-tidine)
- Narcotics
- Polypharmacy
- ETOH
Medical causes of delirium
- Infection (#1): UTI, PNA, Cellulitis, new murmur
- Medication withdrawal
- Hypo/hypernatremia, Hyper/hypoglycemia
- Thyroid dysfunction, Acid-base d/o
- Surgery
Environmental causes of delirium
- Admission to ICU
- Bladder catherization
- Pain (Post Op)
- Emotional Stress
- Sleep Deprivation
Altered level of consciousness
Not just lethargic/stuporous/coma
- Can also be Agitated or vigilant
CAM criteria for delirium
Acute onset with a fluctuating course and Inattention
and one of the following
- Disorganized thinking
- Altered LOC (Hypo or Hyper alert,)
Vegan with delirium
Vit B12 deficiency
Treatment for delirium
Non-pharmacologic
- Sleep Protocol; Sleep/wake cycle, Avoid sedatives (promotes delirium)
- Volume repletion
- Frequent re-orientation
- Taper / discontinue Meds (Beers: TCAs, anticholinergics, etc)
Pharmacologic = Last resort
- Antipsychotics: Haldol (1st line), Olanzapine, Quetiapine, Risperidone
- Benzodiazepines (last line)
Aphasia
Aphasia = loss of ability to use language
Wernicke’s Aphasia:
- Fluent, word salad
- unable to understand written or spoken language
Broca’s Aphasia:
- Non-fluent, expressive aphasia
- able to read but limited in writing
Apraxia
Agnosia:
Disturbed executive functioning-complex thinking:
Apraxia:
- cannot perform task despite strength to do so (eg can’t tie shoes)
- difficulty with speech
Agnosia:
- Inability to recognize specific visual stimuli in the absence of visual impairment
Disturbed executive functioning-complex thinking:
- Inability to plan and sequence events
Normal aging vs cognitive impairment
Normal Aging:
- person remembers later and knows they forgot
- intact learning, stable decline over time
- no functional impairment.
Mild Cognitive Impairment:
- permanently forgotten and is unaware they forgot it
Dementia is defined by impairment in at least 2 cognitive domains:
- Memory
- Executive Function
- Language
- Visuospatial function
- Personality Behavior
Dementia’s Key Features of Diagnosis
Gradual onset (months/years)
- Stable Course
- Cognitive decline is rarely reversible
- Interferes with ADLs/IADLs
Types of dementia in order of frequency
- Alzheimer’s Disease (MC)
- Lewy Body Dementia (Parkinsonian sx)
- Vascular Dementia (strokes, step wise progression)
- Frontotemporal Dementia (Picks Disease)
- Other: Parkinson’s Disease (30%), Huntington Disease, Tumor
Alzheimer’s Disease
MCC of dementia but is a Dx of exclusion
Classic triad
- Memory impairment
- Visuospatial problems; getting lost
- Language impairment; subtle aphasia
- Interferes with social/occupational functioning
- Insidious; NO INSIGHT into their deficits.
Lewy Body Dementia
2nd MC cause of Dementia (AD #1)
1 of 4 present = suggestive; 2 of 4 present = probable
- Fluctuation of cognitive impairment
- Parkinsonism (bradykinesia, rest tremor, rigidity)
- Visual hallucinations (know they’re not real, are not disturbed by them)
- REM Sleep Behavior: Dream enactment; mild-violent punching/kicking
Supported Features:
- Antipsychotic meds sensitivity
- falls
- autonomic dysfunction.
Vascular Dementia
- Sudden onset of cognitive dysfunction
- Stepwise Decline
- Clinical/radiological signs of cerebrovascular disease.
Memory Impairments may be less severe, with “patchy” deficits.
- Brocas aphasia is prominent
FrontoTemporal Dementia (Picks Disease)
Develops younger (50s)
Behavioral Variant (Picks) Highly specific Sx
- Hyperorality (changes in food preference)
- early change in personality, behavior, social awareness [disinhibition]
- compulsive or repetitive behaviors
- sparing of visuospatial abilities
- May develop new artistic talents
Language Variant
- Progressive aphasia
- Semantic Dementia
Dementia; Treatment of cognitive impairment
Cholinestarase Inhibitors
- Donepezil, rivastigmine, galantamine.
- Mild/moderate AD. MCI, DLB.
- Side effects: N/V/D, syncope, bradycardia.
NMDA antagonist
- Memantine
- Mod/Severe AD
- Added to ChEI
Vascular Dementia Treatment
- Reduce Risk factors: HLD, smoking, DM,
- aspirin, clopidogrel
Treatment of Behavioral Problems with dementia
- SSRIs, Olanzapine, Haloperidol
Haloperidol is IM, more of an acute setting Tx
Strokes
Ischemic (MC) or hemorrhagic
Cincinnati stroke scale (1 of 3 = 72% probability)
- Facial droop
- Arm drift
- Speech (slurred or inappropriate words)
Aspirin, plavix
Parkinson Disease Dx
2nd MC neurodegenerative disorder (AD#1)
- Dopaminergic cell loss of substantia nigra
- drug induced with antiemetics & antipsychotics
- Resting tremor: involuntary “Pill Rolling”
- Bradykinesia: Slowness of movement
- Rigidity: stiffness/pain (“lead pipe/cogwheel”)
- Postural instability
- strong response to dopaminergic medications (levodopa)
Parkinson Disease Treatment
Levodopa:
- Converted by DOPA-decarboxylase into dopamine.
- Scheduled: very specific dosing Q 4 - 6 hrs
- SE: “Wearing off” Dyskinesia/choreiform movements, N/V, dizzy/lightheaded
Carbidopa:
- Prevents peripheral conversion to dopamine
Pramipexole, ropinirole
- Dopamine agonists
Drugs capable of inducing secondary parkinson
Anti emetics
- Metoclopramide
- Prochlorperazine
- Promethazine
Antipsychotics
- zapine
- apine
- azine
Both are dopamine receptor blocking agents