Confusion Flashcards by Annie Caldwell

The 6 neurocognitive domains

Complex attention 
Perceptual motor function 
Language function 
Executive function 
Learning / memory 
Social cognition

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Complex attention is made up of…

Sustained attention
Divide attention
Selective attention
Processing speed

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Perceptual motor function is made up of….

Visual perception
Visuo-constructional reasoning
Perceptual motor coordination

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Language function is made up of…..

Object naming
Word finding
Fluency 
Grammar and syntax 
Receptive language

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Executive function is made up of….

Planning
Decision making
Working memory
Responding to feedback 
inhibition 
flexibility

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Learning / memory is made up of….

Free recall
cued recall 
recognition memory 
semantic and autobiolographal long term memory 
Implicit learning

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Social cognition is made up of…..

Recognition of emotions
Theory of mind
Insight

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Diagnosing cause of cognitive impairment - things to find out

Onset
- when 
- how rapid
Course
- fluctuating
- progressive decline
Associated features
- other illness
- functional loss e.g. reduced mobility, reduced self care, new incontinence

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Subtypes of delirium

Hyperactive
Hypoactive
Mixed

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Presentation of delirium

Disturbed consciousness 
(hypoactive, hyperactive, mixed) 
Change in cognition 
- memory / perceptual / language / illusions / hallucinations 
Acute onset and fluctuant 
Disturbance of sleep wake cycle
Disturbed psychomotor behaviour 
Emotional disturbance

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Precipitants of delirium

Infection (not always UTI)
Dehydration 
Biochemical disturbance 
Pain 
drugs 
constipation/urinary retention 
hypoxia 
alcohol / drug withdrawal 
sleep disturbance 
brain injury (stroke, tumour, bleed etc) 
Changes in environment 
Sometimes no idea and multiple triggers

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What is the most common complication of hospitalisation?

Delirium

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Who is delirium common in?

50% post surgery
20-30% of all inpatients
up to 85% last weeks of life

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Diagnosis of delirium

Alterness 
AMT4
- age 
- DOB 
- place
- current year 
Attention 
Acute change of fluctuating course

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What score of 4AT score indicates possible delirium?

4 or above

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What does a score of 1-3 on the 4AT indicate?

Possible cognitive impairment

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Treatment of delirium

Treat cause
- TIME bundle 
Pharmacological measures
- stop bad drugs (anticholinergics, sedatives)
- drug treatment usually not necessary 
- danger to themselves / cannot be settled = quetiapine orally 
Re-orientate and reassure patients (use family / carers)
Encourage mobility and self care
Correction of sensory impairment 
Normalise sleep wake cycle 
ensure continuity of care 
- avoid frequent ward or room transfers 
Avoid urinary catheterisation/venflons

What is dementia?

Acquired decline in memory and other cognitive functions in an alert person sufficiently severe to cause functional impairment and present for more than 6 months

Types of dementia

Alzheimer's
Vascular 
Mixed Alzheimer's / vascular 
Dementia with Lewy bodes 
'Reversible' causes

Features of Alzheimer’s

Slow insidious onset
loss of recent memory first
progressive functional decline

Risk factors for Alzheimer’s

AGE
vascular risk factors
genetics

What is lost first in Alzheimer’s?

Recent memory

Features of Vascular dementia

Classically step wise deterioration
executive dysfunction may predominate rather than memory impairment
often associated with gait problems

Risk factors for vascular dementia

Vascular RFs

T2DM
AD
IHD
PVD

Features of dementia with Lewy bodies

May have parkinsonism Often very fluctuant Hallucinations common falls common

Features of fronto-temporal dementia

Onset often earlier age Early symptoms different from other types of dementia - behavioural change - language difficulties - memory early on not so affected Usually lack of insight into difficulties

What is key in the diagnosis of Dementia

history

Treatment of dementia

``` Non-pharmacological - support for family / carers - cognitive stimulation - exercise - avoiding changes in environment / social support etc - advanced care planning - environmental design Pharmacological - cholinesterase inhibitors - anti-psychotics (avoid if possible) ```

Reversible causes of dementia

``` Hypothyroidism Intracerebral bleeds/tumours B12 deficiency Hypercalcaemia Normal pressure hydrocephalus Depression ```

What is always something to remember in the possible reversible causes of dementia?

Depression

What is delirium also known as?

Acute confusional state | Acute organic brain syndrome

What % of elderly are affected of acute confusional state in hospital?

30%

Predisposing factors to acute confusional state

``` > 65 y/o Background of dementia Significant injury e.g. hip fracture Frailty or multimorbidity Polypharmacy ```

Precipitating evens for acute confusional state

Infection Metabolic (hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration) Change of environment Any significant CVS, resp, neurological or endocrine condition Severe pain Alcohol withdrawal Constipation

What infection in particular particularly causes acute confusional state?

UTI

Presentation of acute confusional state (variety of presentations)

``` Memory disturbances (loss of short > long term) Very agitated or withdrawn Disorientation Mood change Visual hallucinations Disturbed sleep cycle Poor attention ```

Management of acute confusional state

Treat underlying cause Modification of environment Haloperidol 0.5mg first line sedative

What does the 4AT look at?

1. Alertness 2. AMT 4 3. Attention 4. Acute change or fluctuating course

What is looked at in the alertness section of the 4AT?

Normal (fully alert, non agitated, throughout assessment) Mild sleepiness for < 10 seconds after waking, then normal Clearly abnormal

What is looked at in the AMT 4 section of the 4AT?

Age DOB Where they are Current year

What is looked at in the attention section of the 4AT?

Patient is asked to tell the months of the year in backwards order, starting in December. Achieves 7 months or more correctly Starts but scores < 7 months / refuses to start Untestable (cannot start cause unwell / drowsy / inattentive)

What is looked at in the acute change or fluctuating course section of the 4AT?

Evidence of significant change or fluctuation in alertness, cognition, other mental function (e.g. paranoia, hallucinations) over the last 2 weeks and still evident in the last 24 hours