S9 - Dimentia and Delirium Flashcards
what are 5 poss causes of confusion in an elderly patient
dementia delirium drugs depression metabolic (ie acidosis ect)
briefly explain the difference between dementia and delirium
Dimentia is a gradual cognitive decline due to brain disease - progressive loss of memory, intellect and personality
the individual loses the ability to cope with everyday life
delirium is an acute change in consciousness and cognition
Dementia - what are the cognitive symptoms ?
Cognitive symptoms Impaired memory (temporal lobe involvement)
Impaired orientation (temporal lobe involvement)
Impaired learning capacity ((temporal lobe involvement)
Impaired judgement (frontal lobe involvement)
Dementia - what are the non cognitive symptoms ?
Non-cognitive symptoms
Behavioural symptoms • Agitation • Aggression (frontal lobe involvement) • Wandering • Sexual disinhibition (frontal lobe involvement)
Depression and anxiety
Psychotic features
• Visual and auditory hallucinations (hallucinations=false
perceptions)
• Persecutory delusions (delusions=false beliefs)
Sleep symptoms
• Insomnia
• Daytime drowsiness (decreased cortical activity)
how do we diagnose dementia
what do we have to rule out (dont need to remember all of these)
By exclusion • Exclude organic causes of cognitive decline o Hypothyroidism o Hypercalcaemia o B12 deficiency o Normal pressure hydrocephalus Abnormal gait Incontinence Confusion • Exclude delirium
look for gradual cognitive decline
5 key types of dimentia are ?
alzheimer's dementia Dementia with lewy bodies Vascular dementia Frontotemporal dementia AIDS-Dementia complez
outline alzheimer’s dementia
Alzheimer’s disease
frontal, parietal and temporal lobes (hippocampus- memory loss) affected
• Pathological features o Macroscopic Global cortical atrophy Sulcal widening Enlarged ventricles
o Microscopic Plaques • Composed of amyloid beta deposotion Tangles • Hyperphosphorylated tau
It is believed that plaques and tangles kill
neurones.
• Predominant neurones affected o Cholinergic (treatments target this) o Noradrenergic o Serotonergic o Those expressing somatostatin
Dementia with lewy bodies
for this one do pathology and presentation
Dementia with Lewy bodies
• Essentially the same disease as Parkinson’s. If
movement disorder followed by dementia then we call
this Parkinson’s disease. If dementia precedes
movement disorder we call it dementia with Lewy bodies
• Pathology
o Aggregation of alpha synuclein
Forms spherical intracytoplasmic inclusions
Main deposits found across the brain • Substantia nigra • Temporal lobe • Frontal lobe • Cingulate gyrus (found just above the corpus callosum)
• Presentation o Fluctuating cognition and alertness o Vivid visual hallucinations o Parkinsonian features May cause repeated falls
o Do not give antipsychotics (dopamine antagonists)
as can cause neuroleptic malignant syndrome, a psychiatric emergency
Fever Encephalopathy (confusion) Vital signs instability (tachycardia, tachypnoea (v.sensitive sign), fluctuating BP) Elevated creatine phosphokinase Rigidity (caused by dopamine antagonism)
Vascular dementia
Vascular dementia
• Cognitive impairment caused by cerebrovascular disease (multiple small strokes)
• Risk factors same as for any vascular disease (and
indeed same as for Alzheimer’s)
o Previous stroke / MI etc o Hypertension o Hypercholesterolaemia o Diabetes o Smoking
stepwise degeneration w/ each stroke not gradual - symptoms will relate to the location of each stroke
dont forget to manage the risk factors
Frontotemporal dementia
Frontotemporal dementia
• Second most common cause of early onset dementia
- Frontal and temporal lobe atrophy
- Symptoms mostly related to frontal lobe dysfunction
o Behavioural disinhibition o Inappropriate social behaviour o Loss of motivation without depression (caused by damage to anterior cingulate cortex) o Repetitive/ritualistic behaviours o Non fluent (Broca type) aphasia
primitve reflexes - grasp and palmomental reflexes
AIDS-Dementia complex
• Pathology
o Entry of HIV infected macrophages into the brain is
thought to lead to indirect damage to neurones
• Insidious onset but rapid progression once established
• Clinical features (related to global damage but also some
manifestations of cerebellar involvement)
o Cognitive impairment
o Psychomotor retardation (slow thoughts and
movements, also seen in depression)
o Tremor
o Ataxia
o Dysarthria (slurred speech)
o Incontinence
treat with anti viral (HIV)
dementia investigations
FBC U and E TFT's (thyroidisms) hence confusion LFT's Random blood sugar (hypoglycemia and confusion) Vit B12/folate CRP/ESP syphilis testing if needed
outline a general dementia management plan for dementia
Management
Using the bio-psycho-social model
MDT is key
Biological
• Drugs
o Acetylcholinesterase inhibitors (e.g. donepezil,
rivastigmine, galantamine)
Modest efficacy for mild to moderate Alzheimer’s disease
o NMDA antagonists (e.g. memantine)
Useful for treating agitation
anti- anxiety and depression meds
Social
• Mainstay of management
o Finances
o Day care and respite care (mainly to allow carers
to rest and provide supportive environment for
patients)
help for mobility issues
outline what delirium is
Delirium
o Sometimes called ‘acute confusional state’
o Often reversible, due to organic cause
o Dementia can predispose to episodes of delirium
- Rapid onset of confusion
- Clouded consciousness (may be drowsy)
- Often exaggerated emotional responses (aggression)
the two types of delirum are
Hypoactive • Withdrawn • Quiet • Sleepy • Consequently more likely to be missed / confused with something else
Hyperactive • Restless • Agitated • Aggressive Mood may rapidly fluctuate
however a mixed picture can occur
