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Geriatrics > 1: Delirium > Flashcards

1: Delirium Flashcards

(120 cards)

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1
Q

Define delirium

A

Acute, transient, reversible state of confusion usually the result of an organic process

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2
Q

What % of inpatients >65 are affected by delirium

A

50%

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3
Q

What is the mnemonic to remember the causes of delirium

A

CHIMPS PHONED

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4
Q

What are the causes of delirium

A 
Constipation 
Hypoxia 
Infection
Metabolic disturbance
Pain 
Sleeplessness

Prescription medications 
Hypothermia 
Organ dysfunction (renal/liver)
Nutrition 
Environment 
Drugs and alcohol
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5
Q

What 3 prescription medications can commonly cause delirium

A

Tricyclic antidepressants
Anticholinergic drugs
Benzodiazepines

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6
Q

If a patient presents to inpatient care with what 4 factors are they at an increased risk of delirium

A
  1. > 65y
  2. severe illness
  3. hip fracture
    4.
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7
Q

How do individuals with delirium present

A

Globally impaired cognition, perception and consciousness that develops over hours to days and is identified by marked memory deficit, disordered or disorientated thought and reversal of the sleep wake cycle

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8
Q

When are symptoms worse in delirium

A

in the evenings

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9
Q

What are the 3 types of delirium presentations

A

hyperactive
hypoactive
mixed

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10
Q

How does hyperactive delirium present

A 
agitation
restlessness
hallucinations
delusions
aggression 
mood liability
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11
Q

How does hypoactive delirium present

A

excessive sleep
withdrawn
lethargy
inattention

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12
Q

How will a mixed delirium present

A

with symptoms of hyperactive or hypoactive delirium

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13
Q

What test do NICE recommend to confirm delirium

A

Confusion Assessment Method (CAM)

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14
Q

If post-surgery or in critical care what tool is used to diagnose delirium

A

CAM-ICU

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15
Q

What are the 4 features of CAM

A
  1. Acute onset + fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Reduced level of consciousness
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16
Q

What test is commonly used in practice to identify delirium

A

4-AT

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17
Q

What are the four elements of the 4-AT

A
  1. Alertness
  2. AMT4
  3. Attention
  4. Acute or fluctuating course
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18
Q

What is AMT4

A

Age
D.O.B
Year
Place

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19
Q

What type of history should also be performed in individuals with delirium

A

collateral Hx

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20
Q

What will be ordered for individuals with delirium

A

Confusion Screen

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21
Q

What may a confusion screen include

A
  • Obs
  • Medication Review
- Bloods:
  FBC 
  U+E
  LFT
  TFT 
  INR 
  Calcium 
  Glucose 
  Blood Culture 
  Urinalysis and Urine MC+S 
  CXR - if clinically indicated
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22
Q

Why is an FBC ordered in delirium

A 
WBC - indicate infection 
Macrocytic anaemia (B12 deficiency)
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23
Q

Why are U+Es ordered in delirium

A

Urea - cause encephaloapthy + confusion

Hypernatraemia - associated with confusion

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24
Q

Why are TFTs ordered in delirium

A

Hypo + Hyper thyroidism can present with confusion

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25
Why is a serum calcium profile ordered in delirium
Hypercalcaemia can present with confusion
26
Why is glucose ordered in delirium
Hypoglycaemia may cause confusion
27
How should delirium be managed
1. Maintain effective communication with the patient | 2. Treat underlying cause
28
What is first-line if a individual with delirium appears distressed
1. Verbal and non-verbal de-escalation techniques
29
If an individual with delirium is at risk to themselves or others, what should be given
Short course (<1W) haloperidol (0.5-2mg) PO
30
If patients will not take haloperidol PO, how should it be taken
IM
31
What is a contraindication to haloperidol use
Lewy body dementia
32
Define dementia
Clinical syndrome of at least 6 months with chronic + progressive decline in two or more domains of cognitive function (eg. memory + language) in the absence of psychiatric illness or delirium responsible for the impairment
33
What is the most common cause of dementia
Alzheimer's disease
34
What % of dementia is caused by AD
34%
35
What are the 5 types of dementia
1. AD 2. Vascular dementia 3. FTD 4. Lewy body dementia 5. Parkinsonian dementia
36
What % of dementia is vascular dementia
18%
37
What % of dementia is FTD
12%
38
What % of dementia is Lewy Body dementia
7%
39
Name 5 reversible causes of dementia
``` B12 or Folate deficiency Medications Hypothyroidism Neurosyphillis Normal pressure hydrocephalus Depression Subdural haematoma ```
40
Name 5 irreversible causes of dementia
AD, VD, FTD, Lewy body progressive multifocal leucoencapholpathy HIV dementia CJD
41
What are the aggravators of dementia
``` Drugs Emotional illness Medications Eye and ear problems Nutritional disorders Tumour + trauma Infection Anaemia ```
42
What is the course of AD
gradual progressive decline over 8-10 years
43
What are 2 distinctive features to AD
1. loss of episodic memory | 2. language impairment
44
In what order do language features deteriorate
1. Naming 2. Comprehension 3. Fluency
45
How does vascular dementia progress
Often an abrupt onset followed by a step-wise progression
46
What is a distinctive feature of VD
often asymmetrical unilateral onset of symptoms (eg. hemiparesis)
47
What is the course of lewy body dementia
steady decline over 8-10y, but can have a more rapid progression
48
What are 3 distinctive clinical features of lewy body dementia
1. Visual hallucinations 2. Parkinsonism 3. Impaired attention
49
In what age group does fronto-temporal dementia manifest
40-69
50
What are 2 distinctive clinical features to FTD
1. Change in personality | 2. Apathy
51
What is pseudodementia
Often cognitive impairment may present in individuals suffering from dementia. Distinctive feature is that patients often remember the onset
52
What do the majority of patients with alzheimer's disease also have
Vascular Dementia
53
What are 5 genes associated with alzheimer's disease
1. APP 2. Presinilin 1 3. Presinilin 2 4. Apo E2 5. Apo E4
54
What does mutations in APP cause
early-onset AD
55
On what chromosome is APP located
21
56
Why is there though to be an increased risk of alzheimer's disease in downs syndrome
Down syndrome is trisomy 21 - altered APP gene leading to early-onset AD
57
What % of individuals with familial AD have mutations in presinilin 1
50%
58
What is the relationship between ApoE2 and AD
ApoE2 is protective for AD
59
What is the greatest risk factor for AD
Increasing age
60
Name 5 risk factors for AD
- family history - CVD - dyslipidaemia - downs syndrome - HTN - TBI
61
What is the clinical course of alzheimer's disease
gradual decline in cognition over a period of 8-10y
62
What are 5 symptoms of early stage AD
- Impaired concentration - Mild forgetfulness - Inability to learn new material - Poor performance at work - Change in personality
63
What are intermediate symptoms of AD
- Denial - Visuospatial defect - Progressive memory impairment
64
What are 4 late symptoms of AD
- assistance for ADL - difficultly remembering - paranoid delusions - hallucinations
65
What are 3 symptoms of advanced AD
- dependence on others - incontinence - patients may forget their own name
66
Where do amyloid B plaques form
Outside of neurons
67
Where do neurofibrillary tangles form
Inside neurons
68
What is first line Ix for dementia
History from the patient | Collateral history
69
What is then done to investigate dementia
blood test for reversible cause
70
If AD, what tests are then performed
cognitive screening tests
71
What are the 5 cognitive tests are recommended by NICE to look for dementia
1. 10 point cognitive screener 2. 6 item cognitive impairment test 3. 6 item screener 4. memory impairment screen 5. mini cog 6. test your memory
72
What test do NICE not recommend
MMSE
73
What score on the MMSE suggests dementia
24/30
74
What test recommended by NICE is unique to AD
Verbal episodic memory test
75
If the diagnosis is uncertain on cognitive testing, but AD suspected what should be done
FGD-PET | perfusion SPECT
76
What are the 2 non pharmacological treatments for AD
1. group cognitive stimulation therapy | 2. group reminisce therapy
77
What is fist line to treat AD
Acetyl Choline Esterase Inhibitors
78
What are 3 acetylcholinesterase inhibitors
1. Donepezil 2. Rivastigmine 3. Galantamine
79
What is second-line to treat AD
Memantine
80
When should memantine monotherapy be given
Severe AD | Contraindication to AChE
81
What are other medications that may be given in AD
1. Medication to control BP | 2. Antipsychotics - if causing themselves stress
82
What is the prognosis of AD
Often survive 7y post-diagnosis
83
What is the most common cause of death in AD
Infection
84
Define vascular dementia
Global cognitive deficit due to either small or large vessel disease
85
What causes vascular dementia
prolonged or severe cerebral ischaemia either due to: 1. large artery occlusion 2. lacunar stroke 3. chronic subcortical ischaemia
86
What type of ischaemia does occlusion of a large artery cause
Cortical ischaemia
87
What type of ischaemia does a lacunar stroke cause
Subcortical ischaemia due to small vessel occlusion
88
What are 4 risk factors for vascular dementia
1. Age 2. History of stroke 3. Cardiovascular risk factors 4. TBI
89
What are 4 cardiovascular risk factors
1. HTN 2. DM 3. Dyslipidaemia 4. Obesity
90
How will microangiopathic vascular dementia present
symptoms progress more gradually and slower than macroangiopathic
91
How will microangiopathic VD present
subcortical pathology: - impaired memory - gait abnormalities - loss of visuspatial abnormalities - confusion - apathy - mood disorders
92
How will macroangiopathic dementia present
sudden onset of symptoms with often a step-wise progression of symptoms
93
How will macroangiopathic VS present
cortical dementia
94
What are 5 signs of cortical dementia (A's)
``` Amnesia Apraxia Aphasia Agnosia Acalculia ```
95
Explain the pathophysiology of vascular dementia
VD can be due to lesions of small (microangiopathy) or larger (macroangiopathy) cerebral arteries which share common risk factors but present very differently
96
Explain the pathophysiology of microangiopathic dementia
thickening of the vessel intima leads to stenosis, occlusion and even rupture. This results in infarcts of the subcortical white matter causing diffuse white matter lesions.
97
What causes macroangiopathic dementia
Atherosclerosis
98
Explain the pathophysiology of macroangiopathic dementia
Repeated cortical ischaemia events cause progressive damage to neural networks
99
What is a strategic infarct
Infarction in a single (important) area may be sufficient to cause the onset of VD
100
Aside from cognitive testing, what investigation may be used for vascular dementia if the diagnosis is uncertain
MRI
101
What is the non pharmacological management of vascular dementia
Group cognitive stimulation therapy Reminisce therapy
102
When should acetylcholinesterase inhibitors be given in vascular dementia
Only is suspected underlying AD
103
What 3 things should be controlled in VD
BP Weight loss Diabetes
104
What are parkinson plus syndromes
neurodegenerative disease that presents with parkinsonism plus other features
105
In which gender is lewy body dementia more common
Male (4:1)
106
how may lewy body dementia present
Fluctuating cognition Detailed visual hallucinations Parkinsonism develops later
107
What are lewy bodies comprised of
a-synuclein
108
Aside from cognitive testing, what investigation may be performed in suspected lewy body dementia
SPECT | DaT scan
109
What non pharmacological management is given for lewy body dementia
Group reminisce therapy | Group cognitive stimulation therapy
110
What pharmacological management is given for lewy body dementia
acetylcholine esterase inhibitors
111
What acetyl choline esterase inhibitors can be used in lewy body dementia
rivastigmine + donepezil
112
What is second line management for lewy body dementia
memantine
113
What treatment should not be given in patients with lewy body dementia and why
anti-psychotics = may cause irreversible parkinsonism
114
What is fronto-temporal dementia
heterogenous group of disorders that involves degeneration of the frontal, insular and temporal cortex
115
What age does FTD usually onset
40-69
116
How may patients with FTD present clinically
``` Executive impairment Behaviour/personality change Disinhibition Hyperorality Stereotypes behaviour ```
117
What is different in FTD compared to other types of dementia
visuo-spatial awareness and episodic memory are relatively impaired
118
In addition to cognitive screening what investigations may be used it diagnosis in uncertain
FDG-PET | SPECT
119
What should NOT be given in FTD
Acetylcholinesterase Inhibitors or memantamine
120
What is the triad of symptoms of normal pressure hydrocephalus
1. Dementia + Bradyphenia 2. Urinary incontinence 3. Gait abnormalities

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