Confusion in the Elderly

Question 1

Mental health and aging

Answer 1

• Cognitive loss
• Psycological diseases of old age
• Psychosocial issues of the elderly
• Medical legal issues (MDM capacity, dpoa – designated power of attourney)

Question 2

Confusion: the common denominator

Answer 2

• Wrongly believed to be due to aging
• The medical differential diagnosis
• The in-the-trenches differential diagnosis: the three D’s
• You should, for any sx, be able to produce a differential for any give sx

Question 3

The three Ds

Answer 3

• Dementia
• Delirium
• Depression
• If you have altered level of consciousness, these should be your first differentials

Question 4

Confusion in the elderly

Answer 4

• Confusion is variable – the question is how does the confusion present
  
  • Constant versus intermittent – this tells you a lot!
    
    • If you get a UTI, the confusion is intermittent (you won’t be confused for the rest of your life)
  • Acute versus chronic – Parkinson’s doesn’t hit you over night –> if all of a sudden you have all the sxs, that’s NOT Parkinson’s, its probably a side effect from an antipsychotic
  • Differs from symptoms of mental illness in younger people – not everyone has the same adverse drug effects
  • BASELINE –> very important in discussion of cognition
    
    • If their baseline is nonverbal and you assess them and they can’t talk, this is NORMAL FOR THEM
  • No new schizophrenia in old age (but lots of antipsychotics)
    
    • Antipsychotics are used to treat agitation and aggression in the ER and they are also the preferred tx for schizophrenia
    • YOU CAN’T BE A CRACK HEAD AND BE CONSIDERED SCHIZOPHRENIC –> you can’t be on any influence when diagnosed

Question 5

Dementia

Answer 5

• Hallmark: loss of recent memory
• Insidious onset
• Impaired judgement
• Behavioral issues
  
  • Sleep disturbance
  • Aggression
• Early versus late issues
  
  • Early dementia is not the same as late dementia
• Demented people lose their ability to perform ADLs

Question 6

Diseases that cause dimentia

Answer 6

• Alzheimer’s disease 70%
• Multi-infarct (stroke)
• Lewy body (amyloid plaques)
• HIV – late stage HIV people

Question 7

Diseases associated with dimentia

Answer 7

• Parkinson’s disease
• B12 deficiency
• Thyroid disease
• Liver disease
• Encephalopathy – certain disease processes cause encephalopathy (i.e. Hep C, kidney issues)
• These are not dementia in and of themselves but they create dementia à you can use these to prevent dementia

Question 8

Alzheimers dz probable criteria

Answer 8

• Dementia
  
  • Clinical exam eg r/o others
  • Mental status evaluation
• Deficits in >2 cognitive areas
• Progressive decline
• Normal level of consciousness (encephalopathy is NOT a normal level of consciousness)
• Onset between 40-90 yrs
• No other cause
• Supportive factors
  
  • +family hx
  • Cerebral atrophy
  • Normal EEG
  • Normal lumbar puncture
• Clinical criteria + histopathology

Question 9

Alzheimers dz definite criteria

Answer 9

• Risks:
  
  • Nonmod: age, fam hx, APOE-4 gene, down syndrome
  • Mod: head trauma, HTN, DM, smoking, depression
• Age:
  
  • Prevalence of AD doubles every 5yrs > 60
  • 85yo has 50% risk of AD
  • 2x parents with AD = 54% risk by 80yo
  • 1^st degree relative with AD: risk is double that of general population

Question 10

Stages of Alzheimers

Answer 10

• Early
  
  • Gradual memory loss
  • Preserved level of consciousness à they’re aware of where they are, they know whats going on
  • Impaired ADLs
  • Subtle language errors
  • Impaired spatial perception à they are at an increased fall risk
• Late
  
  • Aphasia: no speaking
  • Apraxia: no purposeful actions – think walking à people can walk, but they don’t know where they’re walking to
  • Agnosia: no recognizing/interpreting – they have a hard time understanding language, they cant interpret things in the way that you mean them
  • Inattention
  • Left-right confusion – you say left and they reach to their right

Question 11

Dementia ddx

Answer 11

• Agnosia, aphasia an apraxia shared with other dementias
• AD specific: word finding issues, apathy/indifference, delusion, disorientation
  
  • Delusion = woman who had uterine cancer and refuses blood transfusion because she doesn’t want other people’s blood and she is going to leave and drive across the country

Question 12

Lewy body dementia

Answer 12

• Mild Parkinsonism sxs (shaking, tremor gait)
  
  • Parkinsonism sxs: pill rolling tremor on one side or both sides, shaking, masked facies, shaking
• Unexplained falls
• Visual hallucinations – talking to someone under the bed
• Fluctuating cognition – sometimes theyre with you and sometimes they are not
• Extreme sensitivity to antipsychotic medications
• Confirmation dx: +amyloid plaques on PET scan à DIAGNOSTIC TEST!!
• A diagnosis of Lewy body dementia requires a progressive decline in your ability to think, as well as two of the following:
  
  • Fluctuating alertness and thinking (cognitive) function
  • Repeated visual hallucinations
  • Parkinsonian symptoms

Question 13

Frontotemporal dementia

Answer 13

• Onset before 60
• Language disarray
• Profound personality changes
• Behavioral issues – have a very odd affect
  
  • Impulsive – have no impulse control
  • Hypersexual – sexually motivated

Question 14

Type of Frontotemporal dementias

Answer 14

• Progressive supranuclear palsy: PSP a degenerative disease of specific regions of brain
• Primary progressive aphasia: language slowly impaired, not other mental functions
• Semantic dementia: loss of word meaning
• ALS with dementia: Amytrophic lateral sclerosis (neurogenerative dz)

Question 15

Vascular dementia - multiinfarct dementia

Answer 15

• Stepwise deterioration 2/2 (secondary to) ischemic events
• Normal level of consciousness
• Functional loss may correlate with cerebrovascular events (CT/MRI)
• Types: cortical, subcortical, white matter lesions, mixed or specific – all depend on where the stroke is!
• They have a stepwise approach – every time they have a stroke, their symptomology changes a bit
• YOU DON’T WANT TO MISS VASCULAR EVENTS!!! It’s a red flag! You need to ALWAYS consider a vascular even
  
  • You can get a CAT scan or MRI to confirm
  • You don’t get a CAT scan on everyone you think has dementia
  • ACUTE ONSET à TELLS YOU TO GET A SCAN!!!

Question 16

Confusion in the elderly: dementia

Answer 16

• Diagnosis
  
  • “rule-out” treatable causes (e.g. other D’s)
  • The role of imaging
  • Mental status
    
    • Screening
      
      • MMSE
      • MOCA
    • Full assessment
• Treatment and management
  
  • Education of patient and family
  • Rx
  • Develop strategy for caregiver respite
  • Long-term care planning

Question 17

Mini mental state exam

Answer 17

• Strengths
  
  • Standardized, widely used
  • Reproducible validity
  • Quickly administered
  • Useful scoring
• Limitations
  
  • Does not test executive function
  • No correlative with capacity
  • Screening tool
  • Education dependent
  • Not culturally valid

Question 18

Montreal cognitive assessment

Answer 18

• Visuospatial/Executive
• Naming
• Memory
• Attention
• Language
• Abstraction
• Delayed recall
• Orientation

Question 19

Dementia management

Answer 19

• Facilitate environmental success
• Stimulate cognitive function with challenges
• Promote feelings of pleasure
• Don’t force it

Question 20

Confusion in the elderly: delirium

Answer 20

• Acute onset
• Waxing and waning course
• Common in the hospital
• Memory, orientation, perception, sleep, speech, consciousness and psychomotor hypo and hyper active or mixed changes. Cx: stress causes metabolic changes
• Vast differential diagnosis
  
  • Medications
  • Surgery
  • Infection
  • Dehydration
  • Laboratory abnormalities
  • Associated with other disease process, e.g., cancer, collagen vascular disease, MI, dem, dep
• Marked increase in mortality rate
• Treatment
  
  • Treat the underlying problem
  • Orientation strategies

Question 21

Confusion in the elderly: depression

Answer 21

• 40% of elders experience depression
• Elders do not recognize (or acknowledge) their depression
• Elderly males are the highest suicide risk
• Depression more likely to lead to Parkinson’s dz, alzheimer’s disease, stroke
• s/p stroke: increased likelihood for major/minor depression
• Common symptoms
  
  • Loss of energy and enthusiasm
  • Sleep change: early morning awakening
  • Weight loss
  • Anxiety and perplexing
• Diagnosis: PHQ-2, PH!-9
  
  • PHQ2: lack of interest, depressed mood? Yes to both is 83% sensitive!
• Treatment
  
  • Medication
  • Counseling
  • Education

Question 22

Depression sx

Answer 22

• Sleep – increased or decreased (if decreased, often early morning awakening)
• Interest – decreased
• Guilt/worthlessness
• Energy – decreased or fatigued
• Concentration/difficulty making decisions
• Appetite and/or weight increase or decrease
• Psychomotor activity – increased or decreased
• Suicidal ideation

Question 23

Depression treatment

Answer 23

• 1) SSRI:primary treatment, risk of Serotonin syndrome
  
  • Can cause impotence and weight gain
• 2)SNRI: better for neuropathic pain, eg. Remeron
• ***1 & 2: check Na in 2 wks if on other rx that effect ADH (diuretics NSAIDS, Monitor for GIB/nsaid/asa
  
  • Can create problems with sodium metabolism
• 3) Buproprion: no sex SE, no weight gain no GIB.
• 4) TCAs: SE: anticholinergic, increase HR, orthostasis, monitor EKG!

Question 24

Other depression treatments

Answer 24

• CBT: cognitive behavioral therapy
• PST: problem solving therapy
• TIP: treatment initiation and participation
• ECT: electroconvulsant therapy

Question 25

Mental health issues of the elderly

Answer 25

* Loneliness * Boredom * Vulnerability * Impaired Self-Assessment Skills * Loss * Home * Loved Ones * Respect of the Community * Substance abuse * Alcohol use/abuse

Question 26

Alcohol and elders

Answer 26

* 5.6% Binge Drinking in the Last Month * 2 Million Elders have Alcohol Issues * High Risk Drinkers * 15% Men * 12% Women * Stressful Life Events may be Triggers

Question 27

Screening for alcohol use

Answer 27

* Ask! * Laboratory Clues * Gamma-glutamyl Transpeptidase (GGT) enzyme in liver that indicates liver dz * Mean Corpuscular Volume (MCV) – size of the red blood cell * Microcytic anemia is secondary to GI bleed * Macrocytic anemia = depletion of folate and B12 à ALCOHOLICS!! * Carbohydrate-deficient Transferring (CDT) 4-5 etoh proportion of transfer with fewer chains increased * Screening: CAGE * **C:** felt you should _cut_ down * **A:** been _annoyed_ by others’ concerns * **G:** feel _guilty_ about your drinking * **E:** ever taken a drink first thing in the morning as an _eye-opener_

Question 28

Alcohol and aging

Answer 28

* Low-risk Drinking * At-risk Drinking * Alcohol Abuse * Alcohol Dependence

Question 29

Mental health of the elderly

Answer 29

* End of Life Issues * Recognition of Time Limitations * Hearing Bad News * Accepting Bad News * Preparing for Death

Question 30

Capacity vs. Competence

Answer 30

* Capacity versus Competence * Medical vs legal eg MDM capacity with DPOA * Issue by Issue Determination * Capacity Guidelines * cognitive status * ability to appreciate the problem and its consequences * ability to discriminate risks versus benefits of treatments

Question 31

Assessment of capacity

Answer 31

* Age * Physical Health * Activities of Daily Living * Mental and Emotional Health * Substance Abuse * Acceptance of Services * Financial Resources * Environment * Orientation * Does the Client Understand… * the Situation? * The Potential Consequences of the Situation? * Their Own Limitations in the Situation and the Alternatives Available?