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elderly yr3 > Case 2 - Dementia and Delirium/poor swallow/care planning > Flashcards

Case 2 - Dementia and Delirium/poor swallow/care planning Flashcards

1
Q

How to establish baseline of pt and trajectory over last 12 months?

A
  • Collateral history
  • Abbreviated mental test
  • Mental state examination - anxiety, depression
  • Medication review
  • RF review
  • 4AT test for delirium
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2
Q

Likely causes of poor oral intake in elderly

A
  • Dementia - forgetting to eat
  • Immobility - cannot cook, rely on others
  • End of life?
  • Choking/poor swallow - unpleasant
  • Pain
  • N + V
  • Decreased taste
  • Dentures/poor chewing
  • Slower gastric emptying
  • Depression
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3
Q

Types of fluid consistencies recommended by SALT

A
  • Thin
  • Slightly thick
  • Mildly thick
  • Moderately thick (same as liquidised food)
  • Extremely thick (same as pureed food)
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4
Q

Types of food consistencies recommended by SALT

A
  • Liquidised
  • Pureed
  • Minced and moist
  • Soft and bitesize
  • Regular
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5
Q

Are alternative feeding methods eg NG tube or PEG recommended in dementia and why?

A

No
* Risk of aspirational pneumonia higher
* Unpleasant to have NG tube
* PEG needs sedative/anaesthesia - risk
* Infection risk PEG
* Sores around tubes can result in pt trying to pull out
* Into hopsital for PEG insertion - distressing and may not recover to baseline

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6
Q

What does feed at risk mean?

A
  • Continue to eat and drink despite risk of choking/aspiration
  • QoL is priority - eg advanced illness, swallowing unlikely to improve, tube feeding declined or unsuitable
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7
Q

What is mental capacity?

A
  • Ability to understand, retain, weigh up and communicate information
  • Determines if pt can make decision or if we need to act in best interests
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8
Q

What is a best interest decision?

A
  • Decision made when pt does not have capacity
  • Takes into account patients previous and present wishes, beliefs, history and social history
  • Consult others and act in a way which is best for the patient
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9
Q

What is an advance care plan?

A
  • Plan for future care and support inc medical treatment
  • For people at risk of losing capacity or those who have fluctuating capacity
  • Takes into account feelings, wishes history, ceiling of care, place to be treated etc
  • Ask if informed family
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10
Q

What is a RESPECT form?

A
  • Recommended summary plan emergency care and treatment
  • Takes into account patient preferences of care - priorities over preserving life vs comfort
  • Clinical recommendations
  • DNACPR?
  • Discuss current health and how this may change and treatments which won’t probably work etc
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11
Q

What is delirium?

A
  • Acute confusional state
  • Sudden onset
  • Fluctuating symptoms
  • Develops over 1-2 days
  • Hyper or hypoalert and inattention
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12
Q

Cause of delirium

A
  • Underlying medical problem
  • Substance intoxication
  • Substance withdrawal
  • Or combination
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13
Q

Who is delirium common in?

A
  • Older persons admitted to hopsital
  • Frailer
  • Sensory impairment
  • Cognitive impairment
  • Surgery
  • Hip fractures
  • Severe infections
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14
Q

Important things to exclude as causes of delirium

A
  • Infection
  • Electrolyte imbalance
  • Hypoxia
  • Drugs inc opiates
  • Urinary retention
  • Constipation
  • Uncontrolled pain
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15
Q

How long does delirium take to resolve?

A
  • Anywhere up to 3 months
  • Some people do not get back to baseline
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16
Q

Complications/risks of delirium

A
  • Increased mortality
  • Prolonged hospital stay
  • Higher complication rates
  • Instiutionalisation
  • Increase risk of developing dementia
17
Q

Management delirium

A
  • Supportive care
  • Treat underlying cause
  • Orientate to time and place always
18
Q

When to use pharmacological management delirium?

A

Extreme cases where patient is at risk to themselves or others

19
Q

What does 4AT assessment involve?

A
  • Alertness - sleepy or alert
  • AMT4 - age, DOB, place, current year
  • Attention - please tell me months of year backwards from december
  • Acute change or fluctuating - over last 2 weeks has cognition fluctuated
20
Q

Pharamcological management - ONLY IF AT RISK - for delirium

A
  • Haloperidol - oral and then IM if not
  • Lorazepam if have dementia
21
Q

Types of delirium

A
  • Hyperactive - agitated and confused
  • Hypoactive - withdrawn and drowsy
  • Mixed
22
Q

How to distinguish between delirium and dementia?

A

Collateral history
4AT test useful too

23
Q

What is dementia?

A

Progressive decline in cognitive function usually ocurring over several months
Affects different areas inc:
* retention of new information
* managing complex tasks
* language and word finding difficulty
* behaviour
* orientation
* recognition
* ability to self care
* reasoning

24
Q

Types of dementia

A
  • Alzheimers
  • Vascular
  • Dementia with Lewy body
  • Parkinsons disease with dementia
  • Frontotemporal
  • Mixed - Alzheimers and Vascular
25
Q

Alzheimers dementia presention

A
  • Most common cause
  • Insidious onset (slowly)
  • Slow progression
  • Behavioural problems common
  • Diagnosed with history but brain imaging may show hippocampal atrophy
26
Q

Vascular dementia presentation

A
  • 2nd most common
  • Suggested by vascular RF
  • Imaging suggests vascular disease (ischaemic damage?)
  • Step wise progression
27
Q

Dementia with Lewy body presentation

A
  • Gradually progressive
  • Prominent auditory or visual hallucinations
  • Delusions are well formed and persistent
  • Parkinsonism commonly present but not severe
28
Q

Presentation or parkinsons with dementia

A
  • Parkinsons disease features are present and precede confusion for over a year
29
Q

Frontotemporal dementia presentation

A
  • Onset early
  • Complex behavioural problems
  • Language dysfunction may occur
30
Q

Treatment for dementia

A
  • Cholinesterase inhibitors for Alzheimers to slow progression eg donepezil rivastigmine
  • For vascular - reduce risk factors
31
Q
A

elderly yr3 (14 decks)

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