Session Seven (Unhealthy Ageing; Dementia) Flashcards
What is dementia?
Chronic, progressive disease of the brain.
Affects multiple higher cortical functions including:
- memory
- cognition
- orientation
- comprehension
- calculation
- capacity to learn
- language
- judgement
Associated non-cognitive symptoms include:
- changes in behaviour
- changes in personality
- disturbances of emotional control
- issues around social functioning
- sleep disturbance
What is the link between CVD and dementia?
Almost the exact same risk factors.
Studies suggest a healthy lifestyle in your 40s and 50s can have equal benefits in terms of dementia avoidance as well as CV health.
What is the importance of midlife hypertension?
Hypertension is a treatable cause of cognitive decline and dementia, but its greatest influence on health appears to occur in middle age.
A 20 year long study found an association between blood pressure at the start of the trial and drop in cognitive function seen by the end of it.
(a similar study found that obesity had an increasingly negative impact on performance in a memory and reasoning test after a 12 year interval)
What benefit could the Mediterranean diet have in dementia prevention?
- Maintains low cholesterol
- May be effective in controlling weight and blood pressure
- Special properties of certain foods (e.g. this diet tends to be high in antioxidants)
What can be done to reduce the risk of developing dementia later?
- Healthy diet
- Regular exercise
- Getting enough vitamin D
- Not smoking
- Alcohol in moderation
Describe the onset and progression of Alzheimer’s disease?
Insidious onset and gradual progression over a 7-10 year period.
Early signs =
- miss appointments and meetings
- memory lapses, forget peoples names/ places/ things/ recent events
As the disease progresses =
- difficulties with language
- apraxia (movement issues)
- difficulties with planning and decision making
- deficits in executive function (e.g. performing tasks which involve multiple steps such as getting dressed or cooking a meal)
Describe the onset of Vascular Dementia?
- Stepwise progression
- Marked by acute drop in cognition without any real recovery
- More focal signs than AD
- Loss of executive function such as slowed processing speed, retrieval difficulties
- Lack of rational judgement
- Poor decision making
- Mood disturbances
Describe the onset of Dementia with Lewy body?
- Spectrum of disorders with movement, cognitive, autonomic changes.
- Some overlap with Parkinson’s
- Early visual hallucinations, muscle rigidity, sleep disturbance
Describe the onset of Fronto-Temporal Dementia?
- Generally younger onset
- Changes in personality and behaviour are more marked than in other forms of dementia
- Language impairment
What drugs are most commonly used in Dementia?
- Cholinesterase inhibitors (e.g. Donepezil)
- NMDA antagonists (e.g. Memantine)
What impact does caring for a person with dementia have?
- Permanently changes the relationship between the carer and patient
- Negatively impacts both psychological and physical health
- Financial cost of lost income
- Carers often become isolated themselves (83% report this to some extent)
What is Delirium?
- Disturbance of consciousness
- Reduction in ability to focus, sustain and shift attention
- Change in cognition not better counted for by a pre-existing, established or evolving dementia.
- Development over a short period of time (hours and days)
- Evidence to the cause will normally be found in the history
Why is Delirium considered a medical emergency?
Delirium always has a serious underlying cause (its more true that whatever is causing the delirium is the emergency)
What are the 3 Ds?
Dementia, Delirium and Depression.
3 have a complex interaction, share many similar symptoms and in some ways can all cause each other.
Give some examples of drugs that can c cause delirium?
- Pain killers (opioids)
- Anticholinergics
- Antidepressants (SSRIs)
- Antibiotics (acyclovir)
- Sedatives (benzos)
- Corticosteroids
- CV agents (beta blockers, arrhythmia drugs)
- Anticonvulsants (carbamazepine, phenytoin)
- GI agents (antiemetics, H2 antags)
What can cause delirium?
- Infection
- Electrolyte imbalances
- Thyroid issues
- Pain
- Medication
- Alcohol
When are delirium symptoms worse?
At night
What are the sub-types of delirium?
- Hyperactive (increased motor activity, hallucinations, wandering, inappropriate behaviour)
- Hypoactive (decreased motor activity, lethargy)
- Mixed, many patients fluctuate between the two.
What are the major risk factors for developing delirium?
- Cognitive impairment
- Dementia
- Advanced age
- NOF
- Any other severe illness
Other RFs:
- Admission with infection or dehydration
- Surgery
- Alcohol excess
- Multiple health problems
- Polypharmacy
- Visual impairment
- Renal impairment
How can we prevent a patient developing delirium?
- Keep them hydrated and not constipated
- Adequate oxygen levels
- Prevent infection setting in
- Keep them mobile
- Manage their pain
- Manage their nutrition
- Promote sleep hygiene
How do we treat delirium?
- Identify + treat cause
- Ensure alcohol history is taken and recorded
- Regular monitoring, especially O2 levels
- Avoid constipation and catheterisation
- Encourage early mobilisation
- Ensure adequate nutrition and fluids
- Monitor for verbal and non-verbal signs of pain
- Monitor for pressure areas
- Provide a good sensory environment (clear signage, appropriate lighting levels, consider single room, visible and verbal cues, consider music)
- Continuity of care (may require 1:1 nursing)
- Avoid moving them to a different ward
- Encourage visits from friends and family
What is a ‘This is Me’ form?
A form that someone can fill out for the patient that gives the staff an insight into who they are, what they like and what interests them. Can help the staff reorientate them
When should you consider pharm management in delirium?
If a person with delirium is distressed or if they are considered a risk to themselves or others.
Even then, only once verbal and non-verbal de-escalation techniques have been applied.
What medications are used for emergency delirium treatment.
Haloperidol or Olandzapine, normally a weeks worth of the lowest possible dose (titrate up)
What is the issue with pharmacological management of delirium?
Colossal side effect profile, many of which also effect cognitive functions.
Can lead to:
- Unsteadiness
- Stiffness or tremor
- Difficulty performing ADL
- Slurred speech
- Dehydration
- Water retention
- Increased likelihood of chest infections and blood clots
- Increased risk of stroke
- Premature death
What is a DOLS?
Depravation of Liberties Safeguard.
Law enacted to restrain patients trying discharge themselves when it isn’t safe.
