Reisert: Dementia and Delerium Flashcards
1
Q
acute confusional state with decreased attention that usually lasts over hours to days, but may last months to years
A
Delirium
2
Q
Also known as:
- confusion
- encephalopathy
- acute brain failure
- acute confusional state
A
Delirium
3
Q
- Older age, baseline dysfunction (failing health, dementia, nursing home patients)
- poor sleep
- hospitalization (Catheters, restraints, sleep deprivation, multiple meds, pain)
A
Epidemiology of Delirium
4
Q
Decreased attention is KEY
May have additional sx:
- change in sleep awake cycles
- hallucinations
- delusions
- ANS changes such as HR or BP problems
- hypo or hyperactive status
A
PE features of Delirium
5
Q
- Usually due to diffuse cerebral dysfunction
- May be r/t low Ach levels
- May mimic Alzheimer’s, Lewy body dementia
- High dopamine levels possible
A
Pathology of Delirium
6
Q
Clinical at bedside
Compare baseline function (ask family)
Check for medications:
- anti-cholinergics
- sedatives/narcotics/benzodiazepines
A
Diagnosis of Delirium
7
Q
- ICU/ Post-op psychosis
- Sundowning
- Delirium tremens
A
Delirium syndromes
8
Q
Illness:
sepsis, fever, dehydration, drug abuse
A
Causes of ICU/Post-op psychosis
9
Q
Old people who get worse at night
- common
- worse if underlying mental health issues, especially dementia
Various degrees of delirium
A
Sundowning
10
Q
Maintain day-awake cycle
Night-sleep normalcy
Reassurance/reorientation
A
Treatment of sundowning
11
Q
Mild:
- Tremor
- Agitation, anxiety
DT’s
- Intense reaction
A
Sx of alcohol withdrawal
12
Q
Usually begins 5-10 hours after cessation
Peaks 2-3 days after cessation
A
Alcohol withdrawal
13
Q
Alcohol withdrawal syndrome that is worse in context of illness (hospitalization)
A
Delirium tremens
14
Q
- Agitation
- Tremor
- Hallucinations
- ANS instability (increased BP, pulse, resp)
- Seizures
A
Sx of Delirium tremens
15
Q
treat as status epilepticus
A
Tx for seizures during Delirium tremens
16
Q
Don’t drink
Slow taper off EtOH
Safe enviro/reoreintation/family, B vitamins, hydrate, treat illnesses
Benzodiasepines
Phenobarbital (less proof?)
A
Prevention of delirium tremens
17
Q
- Benzo’s
- Longer acting better
- Diazepam (Valium)
- Chlordiazepoxide (Librium)
- IV or PO
- Bad DT’s: high dose
- Longer acting better
- Phenobarbital
- Antipsychotics
- Haloperidol (Haldol)
A
Tx of delirium tremens
18
Q
Infection
Sepsis
Drugs
Medications
A
Reversible causes of delirium
19
Q
HIgh mortality and morbidity
23-33% die (same incidence as sepsis)
longer length of stay
A
Outcomes of delirium
20
Q
- Toxins
- Metabolic
- liver, kidney, electrolytes, glucose
- Infection
- Endocrine
- thyroid, Vit. B12 def.
- Cerebrovascular
- stroke, seizure/post-ictal, metastasis, HoTN
- Vasculitis
A
Delirium workup
21
Q
Labs (basics-case specific)
Imaging RARELY helpful
Lumbar puncture
EEG to r/o seizures
A
Delirium workup
22
Q
Case by case directed-very difficult
Supportive (reorientation, safety)
Day/night normalcy
Home like enviro
bed alarms/sitters
Antipsychotics (Haldol, new “Atypicals”)
Benzo’s (not as good-sedation)
Bedrails
A
Tx of delirium
23
Q
>4M americans
>$100B annual cost
A
Dementia
24
Q
“Benign forgetfulness of elderly”
May progress to mild cognitive impairment
Can later develop in some
A
Dementia
25
Memory loss
10% \>70 y/o
20-40% \>85 y/o
Dementia
26
Continuum of diease with KEY features
Memory loss (**_KEY_**)
Other problems that develop later:
Speech and language difficulties, problem solving difficulties, impaired judgement, mood issues
Often progresive
Dementia
27
Mood disturbances may or may not be seen
* Depression
* Agitation
* Delusions
* Insomnia
* Disinhibition
Dementia
28
Changes in cerebral circuits
Nerve loss
Changes in neurotransmitters: Acetylcholine, serotonin, glutamine
Neurological features of dementia
29
**Age: by far the greatest**
Viral: Creutzfeldt-Jakob
Genetics?: FH of presence of apolipoprotein ε4-a mutant apolipoprotein that may have implications in amyloid formation
Risk factors for dementia
30
* Alzheimer's disease: **_50% of dementias!_**
* Vascular: 10-20%
* Multi-infarct
* Frontotemporal: Huntington's
* Parkinson's
* With Lewy bodies
* ETOH/Drugs
* Viral/prion disease (Creutzfeld-Jakob: fast progression)
Major types of Dementia
31
Depression
Hydrocephalus
ETOH
Dementia look-a-likes
32
Memory loss is often subtle
Progressive over years
Alzheimer's dementia
33
Neuritic plaques ("senile plaques")
amyloid (Aβ amyloid, Aβ42 amyloid or simply “Beta amyloid”) deposition in arterial walls of neurons
neurofibrillary tangles in cytoplasm of neurons
Pathology of Alzheimer's dementia
34
Affects more women due to longevity
Affects all intellecutal levels, but higher incidence in Down's syndrome
Alzheimer's dementia
35
What must you rule out with ICU/Post-op psychosis?
Stroke!
36
Difficulty with ADL's
lack of recognition of disease (anosognosia)
Behavior changes-may get lost
Word finding issues/other speech difficulties
Can't do puzzles
Dementia
37
* Wandering
* Poor judgment
* Delusions
* Agression
* Sleep disruption, altered sleep-awake cycle
* Incontinence
* Bedridden
* Death (infection, malnutrition, heart disease) in 8-10 years (up to 25)
* Confirm on autopsy
Late sx of alzheimer's dementia
38
Family education
Respite care, adult daycare
Safety (wandering, falls, driving)
Medications
Tx for Alzheimer's dementia
39
A type of vascular dementia
Classically in HTN patients
May progress different
Multi-infarct dementia
40
Larger area, more dementia
Presentation more sudden onset
Looks like AD, may have amyloid, with increase risk of hemmorhage
Vacular dementias
41
Diffuse what matter disease (Binswanger's dx or leukoaraiosis)
Large or small infarcts, lacunar infarcts (HTN)
Vascular dementias
42
Treat risk factors
Medications less helpful
Tx of vascular dementias
43
Huntington's chorea
Pick's disease
Progressive supranuclear palsy
Examples of frontotemporal dementias
44
Memory loss typically later in disease
Attention issues, judgment impairment, awareness, behavior problems
Aphasias seen
Males\>females
Frontotemporal dementias
45
Autosomal dominant inheritance
Chromoome 4
Family history
50% chance of getting
Huntington's chorea
46
Signs: writhing movements (chorea, dancing)
Sx: Motor and cognitive problems (emotional)
Signs/Sx of Huntington's chorea
47
Onet 35-45 years old
After childbearing
Fatal in about 20-25 years
Course of Huntington's chorea
48
Involuntary movements that look like jerks/tics that they can't control
After 10 years --\> movements are slow (Parkinsonoid like) with bradykinesias, rigidity, dystonia
mood changes
cerebral atrophy
Huntington's chorea
49
Family history
Genetic test
Diagnosing Huntington's chorea
50
* Symptom treatment:
* Dopamine blockers (tetrabenazine)
* helps with chorea
* Anti-psychotics
* Anti-depressants
* Genetic counseling?
Tx of Huntington's chorea
51
Anterior frontal and temporal cerebral cortex
Intracellular inclusions (Pick bodies) stain with silver stain
Pick's disease
52
No treatment
Just treat behaviors
Pick's disease
53
* Parkinson's like
* Falls
* Gaze parakysis (can't look down)
* Rigidity
* Dementia
* May development poor judgement, apasia
Treatment: not real helpful
Death 5-10 years
Progressive supranuclear palsy
54
Classic features of Parkinson's with dementia:
Tremor
Rigidity
Masked facies
Bradykinesia
Cogwheeling
Signs/Sx of Parkinson's dementia
55
Do all patients with Parkinson's get Parkinson's dementia?
NO!
56
* Visual hallucinations
* Parkinson’s features
* Decreased alertness
* Presentation often delirium in face of infection or given L-dopa drug for Parkinson’s and get delirium
* Episodic confusion that waxes and wanes, but persists
* Lewy bodies are intraneuronal cytoplasmic inclusions that stain with PAS staining
* May have cholinergic defect
* May overlap with other dementias
Signs/Sx of dementia with Lewy bodies
57
Treatment for dementia with Lewy bodies?
Anti-cholinergic drugs
58
Gate ataxia
Dementia
Urinary incontinence
Normal pressure hydrocephalus
59
Imaging shows large ventricles
Some use MRI for imaging
Some use supervised CSF tap
DIFFICULT diagnosis to make
Diagnostics for normal pressure hydrocephalus
60
Treatment for normal pressure hydrocephalus?
Shunting
61
* Long term use
* Vitamin deficiences: Wernicke's encephalopathy
* Thiamin deficiency
* Confusion, ataxia, diplopia due to opthalmoplegia
Ethanol induced dementia
62
Treatment for Wernicke's encephalopathy/Thiamin deficiceny?
100mg IV thaimin x 3 days
63
Can't recall recent memory despite immediate memory retention
Get easily confused
Confabulation
Korsakoff's syndrome
64
Often spinal cord issues (myelepathy)
Macrocytosis
Treatment: replace wtih sv Vit. B12
Vitamin B12 deficiency
65
Not a dementia
Awake and fine then later forget a moment of time
SCARY patient
Transient global amnesia
66
Etiology of transient global amnesia?
Somewhat unknown?
Migraine, stroke?
67
Tx for transient global amnesia?
Reassurance!
68
Perhaps **_the most important thing!_**
Wrong diagnosis --\> wrong treatment
Recognition and diagnosis of dementia
69
What are some histories seen with dementia?
* memory loss, duration
* Other sx (driving, shopping, eating, depression, erratic behavior, hallucinations, tremor/Parkinson's)
* Strokes/CV risk factors (esp. multi-infarct dementia)
* HIV.syphilis
* head trauma (hydrocephalus)
* Nutrition isses (ETOH/thiamin deficiency, gastric bypass/obesity surgeries)
70
History
Mini-mental status exam
Full neuropsychiatric testing
Parkinson's features?
Atrial fibrillation, HTN, etc
Labs: B12, Thyroid recommended by American Academy of Neurology
**Exam/Work up for \_\_\_\_\_?**
Dementia
71
Delay progression of disease
Improve caregiver fatigue
decrease agitation
Pharm therapy in dementia
72
CT or MRI
Looking for:
atrophy, hematoma, infarction, tumor
Imaging for dementia
73
It is also important to treat who in dementia?
Caregivers
