COTE Flashcards
(123 cards)
Define delirium
An acute and fluctuating disturbance in consciousness
Describe the key features of delirium
-change in cognition: widespread memory impairment, disorientation, language disturbance, hallucinations
-acute onset/fluctuating: onset over hours or a few days with severity worsening throughout the day
-disturbance of consciousness: decreased ability to focus or sustain attention, distractibility, losing track of conversations
Other: sleep disturbance, emotional disturbance, delusions and restless or listless
What are the two main types of delirium?
Hyperactive: agitation, aggression, psychotic symptoms, oversensitive to stimuli, repeatedly getting out of bed/trying to wander
Hypoactive: lethargic, quiet, few psychotic symptoms, slower speech/not talking (less commonly diagnosed so worse prognosis)
can be mixed
What are the predisposing factors for someone developing delirium?
Old age <65 years old
Cognitive impairment eg dementia
Frailty/multiple comorbidities
Significant injuries eg hip fracture
Surgery
History of (or current) alcohol excess
Sensory impairment eg deaf or blind
Lack of stimulation
Terminal phase of illness
Surgery
Polypharmacy
What are the causes of delirium?
Infection: viral/bacterial eg UTI, pneumonia, biliary infection
Drugs: changes to medication/new medication OR illegal drugs eg in a younger person
Electrolyte/Fluid imbalance: dehydration, hypercalcaemia
Alcohol or drug withdrawal
Organ failure eg cardiac
Endocrine: hypo or hyperthyroid or low/high blood sugars
Epilepsy
Intercranial pathology: have they had recent head trauma?
Pain
CONSTIPATION (in elderly people)
Changes to environment eg home –> hospital, family/carers not around, overstimulation in hospital environment
Give the drug classes and examples of drugs that can cause delirium
Anticholinergics: atropine
Antipsychotics: chlorpromazine, thioridazine
Antidepressants: tricyclics
Opiates: codeine, tramadol
Corticosteroids: prednisolone
Investigations for delirium
Basic obs at bedside: are they in pain, BP, pulse ox, last time BO
Bloods:
-confusion screen= U&Es (dehydration/hypercalc), B12, TFTs, glucose
-FBC
-Coagulation eg intercranial bleed?
CXR- pneumonia?
Mid-stream urine/urinalysis- UTI
Management for delirium
Non-Medical: quiet environment, ensure patient gets enough sleep, presence of family/carers, use of clocks to orient to time, familiar objects, calm manner when dealing with the patients, keep routine as similar as possible
Medical: treat cause if possible eg
-antibiotics: pneumonia or UTI
-plenty of fluids and nutrition to avoid patient becoming dry
-laxatives for constipation
-pain relief if in pain
Drug management for delirium
-only if patient is threatening safety of themselves/others or interfering in medical treatment
-should be used as a last resort
-minimum effective dose
-dose PRN
-short acting benzodiazepines eg lorazepam
Differences between delirium and dementia
Delirium:
-acute/subacute
-often reversible
-fluctuation common throughout the day
-poor attention
-conscious level usually affected but may be subtle
-hallucinations and misinterpretations common
-agitation and aggression common
-disorganised thought and unreal ideas
-motor signs inc tremor or asterixis
-poor short AND long term memory
-dysgraphia
Dementia:
-chronic onset
-rarely reversible
-little diurnal variation
-poor attention in severe dementia
-normal conscious level
-hallucinations in later disease
-agitation and aggression uncommon in early disease
-disorganised thought in later disease
-motor signs only later
-speech normal
-dysgraphia present later
-long term memory often normal till later
Define dementia
Progressive and acquired decline in the memory and cognitive functioning of an alert person with daily life significantly affected
Describe the pathology of Alzheimer’s disease
Pathological changes:
-deposits of beta-amyloid plaques occur outside of neurons. Amyloid precursor protein (APP) helps neurones grown and repair. Normally broken down by alpha secretase and gamma secretase into a soluble peptide. If beta secretase breaks down APP, it creates a monomer called amyloid beta, which is sticky. They can bind together to form the beta amyloid plaques.
-Neurofibrillary tangles made of the protein tau which holds the tubules of the neuron cytoskeleton together. The beta amyloid plaque build up leads to the activation of kinase inside the neuron. This leads to phosphorylation of the tau protein, changing its shape and clumping with other tau proteins.
Neurones with tangles do not function as well and end up apoptosing and the brain begins to atrophy.
What are two most common types of dementia?
Vascular dementia and Alzheimer’s
Describe the symptoms and progression of Alzheimer’s
Insidious onset, with progressive but slow decline.
-poor memory
-language problems
-disorientation
-agitation
-sleep disturbance
-anxiety and depression
-withdrawal/apathy
-motor disturbance
-loss of independence
Early stages begin with profound short term memory loss and issues with high functioning eg finances leasing to later stages of broad cognitive dysfunction and behavioural changes
Describe the investigations and their findings in Alzheimer’s
Physical exam- normal
Neuroimaging- shows no other causes of dementia eg infarct with disproportionate medial temporal lobe atrophy
Cognitive assessment: MMSE assesses different areas of higher cortical functioning
Describe the pathology of vascular dementia
Vascular dementia is a progressive loss of brain function caused by long term poor blood flow to the brain usually because of a series of strokes
Atherosclerosis in arteries to the brain leads to plaques breaking off and blocking smaller arteries or small arteries can get completely blocked with plaque growing inside them
Once blood flow to parts of the brain is stopped, the tissue becomes damaged leading to necrosis and a loss of mental functions governed by that area
Describe the symptoms and progression of vascular dementia
Progression is often a sudden decline in function and appears stepwise, with cognitive impairment patchy vs the uniform impairments of Alzheimer’s
-front lobe symptoms: falls, depression, reduced creativity, impaired judgement
-extrapyramidal symptoms: parkinsonism, restlessness, involuntary muscle contractions
-pseudobulbar features: involuntary outbursts of emotion
-other features mimic Alzheimer’s eg memory issues, language problems etc
-depression and apathy also common symptoms
Urinary incontinence and falls without other explanation are often early features
Describe the investigations and their results in vascular dementia
Physical exam: focal neurology showing hyperreflexia, extensor plantars, abnormal gait
Neuroimaging: multiple large vessel infarcts OR a single critical infarct eg thalamus OR white matter infarcts or periventricular white matter changes OR microvascular disease that may be too fine to be seen on neuroimaging
Describe the general dementia management
General: modify reversible aggravating factors eg constipation, drug side effects, mild anaemia and treat depression with SSRIs. Carers for helping with ADLs, medications etc
Social: encouraging physical and mental activity, creating a safe and caring environment with a predictable routine PLUS respite and support for caregivers/family.
Practical: simple interventions eg alarms & calendars and simplifying medication eg with dosette boxes
Contraindications for starting anti-cholinesterase inhibitors?
QT prolongations, second or third degree heart block in an unpaced patient, sinus bradycardia of <50bpm
May make incontinence worse
Describe the medical management of Alzheimers & Lewy Body dementia
Acetylcholinesterase inhibitors: they work by blocking acetylcholinesterase which breaks down acetylcholine
-mostly useful in Alzheimer’s, Lewy body and Parkinson’s disease dementia as they have the greatest cholinergic deficits- rivastigamine, galantamine, donepezil
Memantine: blocker of NMDA receptors that may reduce glutamate mediated destruction of cholinergic neurons
What are the factors that influence fall frequency?
Intrinsic factors: maintaining balance is complex- requires good muscle strength, stable joints, multiple sensory modalities and a functional peripheral/central nervous system.
Extrinsic factors: environmental factors eg lighting, steps, shoes, floor surface, presence of rails
What are the factors that influence fall severity?
-multiple system impairments leading to less effective saving mechanisms
-osteoporosis and increased facture rates
-secondary injury due to post fall immobility eg bed sores, pneumonia and dehydration
-psychological adverse effects eg loss of confidence
List some possible causes of falls
cardiovascular: arrhythmias, orthostatic hypotension, bradycardia, valvular heart disease
Neurological: stroke, peripheral neuropathy
GU: UTI, incontinence
Endocrine: hypoglycaemia
MSK: arthritis, disuse atrophy
ENT: benign paroxysmal positional vertigo, ear wax
Polypharmacy
