W8_Delirium_Dementia_24 Flashcards
What are the common mental disorders in elderly?
4D+P
- Delirium
- Dementia
- Depression
- Disorder (Anxiety Disorder)
Psychosis (Late onset)
Confusion vs Acute Confusion
L1, L2, L3
Confusion
–> Disturbance of consciousness
–> Inappropriate reactions to environmental stimuli
Acute Confusion
–> Delirium (Acute Confusional state) (Fluctuating consciousness)
3 Questions to ask
1) Is the patient confused (Ask: T,P,P)
2) Is the confusion acute or chronic?
3) Is it reversible or irreversible?
What are the 3 questions to ask for patients suspected of confusion?
How is it different from disoriented?
Disoriented vs Confused
3 Questions to ask
1) Is the patient disoriented? (Ask: T,P,P)
2) Is the confusion acute or chronic?
3) Is it reversible or irreversible?
Level 1: Disoriented
Level 2: Confused
Level 3: Acute State: Delirium
What are the 3 sub-classification of Delirium
Classification of Delirium
1) Delirium with normal brain
full recovery expected
2) Delirium with
previously undiagnosed early dementia
*aim is to return to premorbid state*
3) Delirium with established dementia
to treat urgently to prevent further decline in mental function
What are the predisposing factors of Delirium?
- Impaired sensory functioning & sensory deprivation
- Sleep deprivation
- Immobilization (deprivation movement)
- Transfer to an unfamiliar environment
- Psychosocial stresses
What are the causes of Delirium?
- Constipation
- Urinary retention
- Infections
- Polypharmacy
- Cerebral hypoxia
- Metabolic disorders
- Endocrine causes
- Intracranial lesions
- Trauma & pain
Management for Delirium
- Admission
- Diagnostic tests
(Identify treatable and reversible causes) - Appropriate specific treatment
- Good supportive care (hydration, nutrition, avoidance of restrainers & bedsore prevention, bladder & bowel care & speedier recovery)
- Quiet environment with good lighting & warm, friendly & reassuring staff
- Sedatives to be used with caution
How to Apply the CAM Diagnostic Algorithm
Confusion Assessment Method (CAM)
Feature 1: Acute onset and fluctuating course
Is there an acute change in mental status from the patient’s baseline? Did this behavior fluctuate during the past day (tend to come and go or increase and decrease in severity)?
Feature 2: Inattention
Does the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
**Feature 3: **Disorganized thinking
Is the patient’s speech disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas,
or unpredictable switching from subject to subject?
**Feature 4: **Altered level of consciousness
Overall, how would you rate this patient’s level of consciousness?
Alert (normal) Vigilant (hyperalert)
Lethargic (drowsy, easily aroused) Stupor (difficult to arouse)
Coma (unarousable)
The diagnosis of delirium requires a present/abnormal rating for features 1 & 2
and also for either feature 3 or 4.
Diagnostic Algorithm for CAM
The diagnosis of delirium requires a present/abnormal rating for features 1 & 2 and also for either feature 3 or 4.
Feature 1: Acute onset and fluctuating course
Feature 2: Inattention
Feature 3: Disorganized thinking
Feature 4: Altered level of consciousness (LOC)
DSM V Criteria for MND
(Major Neurocognitive Disord
er) (Dementia)
Evidence of cognitive decline from previous level of performance in one or more cognitive domains (Complex attention, executive function, learning and memory, language, perceptual-motor or social cognition) based on:
- Concern of the individual, a knowledgeable informant or the clinician that there has been a significant decline in cognitive function; and
- A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing.
B. Cause interference in everyday activity.
C. Is not due to delirium
D. Not due to any other medical condition
10 Warning signs of Dementia
- Recent memory loss that affects job skills
- Misplacing things (memory)
- Problems with language
- Poor or decreased judgment
- Problems with abstract thinking (cognitive)
- Difficulty performing familiar tasks (cognitive)
- Disorientation with time and place (cognitive)
- Changes in mood or behavior
- Changes in personality
- Loss of initiative
Pharmacological Treatment for Dementia
Disease modifying agents
1) Acetylcholinesterase inhibitors
(donepezil, rivastigmine, galantamine)
Common side effects: N&V, agitation, giddiness, bradycardia
2) NMDA antagonist (memantine)
N&V, giddiness,
- Antipsychotics
(risperidone, quetiapine, olanzepine, haloperidol)
Anticholinergic effects, extrapyramidal side-effects - Antidepressants
(fluvoxamine, escitalopram, mirtazepine)
Anticholinergic effects, hypotension - Mood stabilizers (sodium valporate)
Thrombocytopenia, bleeding tendencies - Benzodiazepines
(lorazepam, clonazepam)
Hypotension, sedation
What are the complications of Dementia?
BPSD
Biological
Psychological
Symptoms of
Dementia
Pharmacological Treatment for
Suicidal Older Adults
Anti-depressants
- Newer generations (SSRIs) used as first line
Safer if overdosed
fewer anticholinergic side effects
E.g. fluoxetin, fluoxamine, escitalopram, sertraline
- Tricyclic antidepressants (might not be suitable for the older populations as it can cause cardiac arrhythmia)
E.g. imipramine, amitriptyline, nortriptyline - MAO inhibitors
E.g. phenelzine, trancylopramine
Response ~80%
Elderly may take longer to respond and may require a longer period of treatment - Other psychotropic agents
Benzodiazepines E.g. lorazepam, clonazepam
Antipsychotics E.g. risperidone, quetiapine, olanzepine
Mood Stabilizers E.g. sodium valproate, lithium
