quiz 1 Flashcards
what is delirium
-Acute, transient, usually REVERSIBLE confusional state
-alteration of consciousness with reduced ability to focus, sustain, or shift attention
-Results in cognitive or perceptual disturbances that is not better explained by a pre-existing, established, or evolving dementia
-Develops over a short period of time (hours to days)
-underlying pathology present with not well understood pathophysiology
-can be the only sign of acute illness in elderly
-Very common in acute hospitals
delirium risk factors + precipitating factors
Risk
-Advanced age
-Recent surgery
-Pre-existing brain disease (e.g. dementia, stroke, Parkinson’s)
-30% of elderly patients experience delirium during hospitalization -> Higher rates in ICUs
Precipitating factors:
-Polypharmacy
-Infection
-Dehydration
-Malnutrition
DSM criteria for delirium
- Disturbance in attention and awareness (1st)
- distractability = hallmark - Develops over short period of hours
- days; most severe night/evenings - Cognitive disturbance including perceptual
- ex: memory deficit, disorientation, language, visuospatial ability, perception
4.Not explained by another neurocognitive disorder or coma - Evidence (h&p,labs) that disturbance is caused by medication, condition or substance
course of delirium: what phases
- Prodromal phase (often not caught)- fatigue, sleep disturbance, depression/anxiety, restlessness, irritability, hypersensitivity to light or sound
- perceptual disturbance and cognitive impairment
- quiet/hypoactive - not interacting with environment (mc) OR agitated and confused
signs of delirium
-Change in level of consciousness
-Inability to direct, focus, sustain or shift attention
-Memory loss, disorientation, difficulty with language or speech -> Speech may be tangential, disorganized, incoherent
-Advanced: drowsy, lethargic, semi-comatose
It is important to get a good HISTORY on these patients, look for:
-Recent febrile illness
-hx of organ failure
-medication list and changes
-alcoholism or drug abuse
-recent depression
It is important to get a good HISTORY on delirium patients, look for what signs + what test to perform
look for:
-Recent febrile illness
-hx of organ failure
-medication list and changes
-alcoholism or drug abuse
-recent depression
tests:
- MMSE
- test attention: serial 7s or spell “world” backward
-Focused exam on hydration status, skin, vitals and sources of infection
MC etiologies of delirium
-Post operative states (very common in elderly)
-Drug toxicity (30% off all cases)
-Fluid / Electrolyte disturbance - NATREMIA, dehydration
-Infections- UTI, skin and soft tissue, pneumonia
-ETOH or other substance intoxication
-Barbiturates, benzodiazepines, ETOH withdrawal
-Metabolic disorders - shock
-Low perfusion states
drug culprits of delirium
-NSAIDs *
- Opioids*
-Benzodiazepines*
- anticholinergics: diphenhydramine**
-Acyclovir
-Antimalarials, Interferon, Amphotericin B, Cycloserine
-Cephalosporins, Fluoroquinolones, Macrolides, Metronidazole, Penicillins, Sulfonamides, Aminoglycosides, Linezolid
-Isoniazid, Rifampin
-Corticosteroids
-Hypoglycemics!
-CV: antiarrhythmics, BB, Clonidine, Digoxin, Diuretics, Methyldopa
-CNS-active agents: Lithium, IL-2, Phenothiazines, Donepezil
-Anticholinergics: atropine, benztropine, scopolamine, trihexyphenidyl, diphenhydramine!!!!!
-Dopamine Agonists: Amantadine, Bromocriptine, Levodopa, Pramipexole, Ropinirole
-Anticonvulsants: carbamazepine, levetiracetam, phenytoin, valproate, vigabatrin
-GI: antiemetics, antispasmodics, H2 Blockers, Loperamide
-Muscle Relaxers: Baclofen, Cyclobenzaprine
-Herbals: St. John’s Wort, Valerian
tx and prevention of delirium
-treat underlying cause
-treat their distress
-antipsychotic rarely needed (<10%)
-optimize conditions for brain recovery
-orientation protocols and psychological support
-monitor for recovery
-resolves in less than a week usually
-antipsychotics: Haloperidol, Risperidone, Olanzapine, Quetipaine, Aripiprazolex
major neurocognitive disorder (DEMENTIA)
-Progressive and gradual deterioration! of selective functions
-Must represent decline from previous baseline and severe enough to interfere with daily function! and independence
-Cognitive decline involving 2+ domains:
-learning
-memory (new information)
-language
-executive function (complex tasks, poor judgement)
-complex attention
-perceptual-motor
-social cognition
-Risk factors: age (>60 y/o), vascular disease (HTN, DM)
-MC cause: Alzheimer Disease (60-80%)
-Less common causes: alcohol-related, CTE, normal pressure hydrocephalus, chronic subdural hematoma, CNS illness (Creutzfeldt-Jakob disease, HIV), copper/B12/Folate deficiency
-AAN and USPSTF recommends routine screening for dementia in asymptomatic adults
clinical manifestation of dementia
-1. memory loss- 1st manifestation- presents as forgetfulness (trouble remembering recent events)
-2. Deficits in other cognitive domains (with or after memory loss)
-(a) Executive dysfunction (less organized/a, difficulty multitasking) - early
-(b) Impaired visuospatial skills (getting lost in familiar places) - early
-(c) Language dysfunction (word finding) – late
-(d) Behavioral symptoms (apathy, social disengagement, irritability; agitation, aggression, wandering, psychosis) – middle/late
-3. Non-cognitive neurologic deficits – late
-Pyramidal/Extrapyramidal motor signs, myoclonus (uncontrollable twitching), seizures
-(4) Life expectancy after diagnosis: 8-10 years (range: 3-20)
dementia exam: assessment
-MMSE or MoCA
-Complete physical exam
-Labs:
-Routine labs such as CBC, CMP, Calcium, UA
-B12 deficiency and hypothyroidism screening (AAN recommendation)
-Any other indicated labs based on their history / physical (ex: heavy metal, ETOH/Drug screening, syphilis)
-Imaging: MRI brain without contrast (AAN recommendation, over CTH)
-Consider:
-LP: rule out infectious, inflammatory, neoplastic causes
-EEG: Atypical syndrome with concern for Creutzfeldt Jakob disease (less than 60 years old, rapidly progressive symptoms)
-PET: distinguish a vascular cause from Alzheimer’s
-Brain biopsy: definitive but rarely done
alzheimers dementia (AD)
-Most common cause of dementia (60-70%)
-Pathophysiology:
-Accumulation of !amyloid beta (Aβ) deposition in the brain that forms neuritic (senile) plaques and neurofibrillary tangles (NFTs) composed of tau protein filaments! with eventual loss of neurons (PANCE question)
-Often a cholinergic deficiency causing memory, language, and visuospatial changes early on
-Major genetic risk factor: ε4 allele of the apolipoprotein E (ApoE) gene
-RF: !Age > 65!, female, family history, CVD, APOE-e4 allele
AD dx and management
-dx -> excluding other etiologies of dementia
-CT/MRI brain:
-Brain atrophy- Medial temporal lobe (reduced hippocampal volume)!
-Mild ventricle dilation
-Management:
-Acetylcholinesterase inhibitors: DONEPEZIL!! 10mg QD (1st line), rivastigmine
-Reverses cholinergic deficiency
-Side effects: GI upset (nausea/diarrhea/cramps), altered sleep w/ vivid dreams, bradycardia, muscle cramps
-NMDA antagonists: Memantine -> Blocks NMDA receptor, which means it blocks the excitatory glutamate, which can cause cell death
-Vitamin E
concussion: return to play protocol
any LOC episode -> ER for evaluation
-Suspected Cervical -spine injury -> immobilize, ER
-High impact, high risk -> ER
-Skull fracture findings -> ER
-Seizure post trauma -> ER
-Focal neuro signs (weakness, confusion, or imbalance) -> ER
Suspected concussion should be removed from play immediately -> When in doubt, sit them out!”
-Re-evaluation in 1-2 days with specialist
-Clearance by licensed health professional usually requires symptom resolution off meds
meningitis csf findings
