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Flashcards in Delirium and dementia Deck (29)
1

What's the difference between dementia and delirium?

Dementia is a progressive and largely irreversible clinical syndrome that is characterised by a widespread impairment of mental function.
Delirium is an acute, usually temporary condition characterized by disorientation, hallucinations, anxiety, incoherent speech, restlessness and delusions.

2

What are the different forms of dementia?

Lewy body dementia
Alzheimer's
Fronto-temporal dementia
Prion diseases
Vascular dementia
'Others' eg HIV associated dementia (can be partially reversed with HAART therapy)

3

How can you define dementia?

• Short term memory impairment may be the start of dementia, but it is not itself dementia
• Dementia has to be both global and progressive to be worthy of the name
• Dementia is not defined by a Folstein Mini-Mental State, nor any other test for that matter
• We need both an informant’s description and some psychometric testing: and some other tests

4

What is Alzheimer's disease?

• A gradually progressive dementia with short term memory loss and progressive global change in another domain such as language, apraxia,
• Behavioural and psychiatric changes may occur
• Often loose insight
• CT brain may show medial temporal lobe changes but is often normal

5

What is Lewy body dementia ?

A form of dementia with some overlap with Alzheimer’s disease.
Characterised by some features of Parkinsonism.
Often, have gait instability and falls at an early stage. Formed visual hallucinations (usually non-frightening). Marked fluctuation within and between days Daytime sleepiness with sleep reversal and bad dreams Extreme sensitivity to neuroleptics.

6

What is vascular dementia?

Overlaps with Alzheimers
Due to multiple strokes, large or small
Extensive MRI evidence of strokes can exist with little clinical evidence of dementia. But it’s a poor prognostic sign.
May have clinical evidence of previous strokes, arteriopathy elsewhere
Mood disorders frequent: in fact, a high “white matter burden” indicates a poorer prognosis in depression
Characterisitic “stepwise” progression is possible but a slow “slide” is commoner.

7

What is stroke related dementia?

Symptoms may appear suddenly. Over a period of time a person may have further strokes which result in cognitive and frequently physical disabilities.

8

What is small vessel disease related dementia?

Tends to be more like Alzheimer's, developing slowly over time.

9

What are Prion diseases?

Creutzfeldt-Jakob Disease
- older people: uncommon: incidence about 1 in a million
- 85% sporadic, 15% familial
New Variant CJ disease
- younger people, behavioural problems at onset
- BSE agent: uncommon: peak reached ?
Fatal Familial insomnia
Kuru
- rare, largely hereditary - transmission through eating neural tissue
Gertsmann-Sträussler-Scheinker (GSS) disease
- v rare: all familial
Alcohol abuse is very common indeed and is associated with subdural haematomas as well as cerebral atrophy and W-K syndrome

10

What is Pick's disease?

Fronto-temporal dementia
Presents with disinhibition language disorder
loss of social skills poor judgment abulia personality change overeating, hyperorality unable to use everyday objects
Arnold Pick, 1892
Short-term memory often not too bad: FMMSE fails to pick up Imaging may show atrophy of fronto-temporal lobes

11

What is common in a dementia patient's medical history?

• Shortterm-memory
- Forgettingthings - Forgettingpeople - Repetitive questions - Forgetting what just happened
Story of getting lost in a familiar place Getting up in the night and thinking it’s day Getting lost whilst driving Missing appointments, etc.
• Languageability - inability to manipulate language to express
themselves - inability to understand requests.
• Constructionalability/apraxia - can’t get dressed in sequence - unable to do sequence tasks.

12

What tests can be performed on a possible dementia patient?

Test immediate and delayed recall: - Ball, Flag, Tree
- Name and address - Details of a story or picture - Things in their life of note
• Test their Orientation
- in place - in time - in person
To test language ability: Listen to speech carefully Name objects (Pen, Watch, Keys) Describe what’s happening in a picture.
To test apraxia:
Draw complex shapes (double pentagon) Follow instructions (3-step test) Watching someone dress or do a task Clock-face drawing.
To test frontal lobe (executive) function - social and personal behaviour - ability to look after self:
Sequencing tasks/series Interpretation of abstract concepts (proverbs) Language fluency and content Cognitive rigidity Verbal fluency.

13

What is The Folstein Mini-Mental State?

plusses:
 Easy
 Quick (5-10 mins)
 Very widely used
 Assesses several domains
 Robust (not much inter-observer variation)
 Useful best screen available
negatives:
 Crude
 Sensitive to educational level
 Insensitive to mild cognitive impairment
 Does not test frontal lobe function well
 Confounded by language (in)ability

14

How do you estimate premorbid intelligence? (what to look at to measure intelligence before disease kicked in)

Vocabulary:
Over-learned
Wide vocabulary is associated with a high IQ (National Adult Reading Test)
What job they held when working
Educational achievement
Assortive mating

15

Which Dementia types are associated with gait disorder?

• Lewy Body disease
• Vascular dementia
• Normal pressure hydrocephalus
• Mass lesion (tumour/haematoma)
• Co-incidence of dementia plus another cause of gait disturbance
• “Parkinsons-plus” disorders

16

When can a history sound much more impressive than the psychometric testing?

• Frontal lobe problem • Additional mood disorder
• Additional psychosis • Additional medical pathology
• High intelligence / educational level

17

When can a history sound much less impressive than the psychometric testing?

• Denial in the informant
• Very good social “front”
• Is there a language or communication problem making the patient score less well, such as deafness or dysphasia ?
• Low educational level or poor literacy • High educational level

18

How can you tell the difference between dementia and depression?

 Can look really quite similar: lack of drive, interest, ability; neglect of self-care, etc
 Can, of course, co-exist
 Older people with depression have higher amounts of white matter changes on MRI, and when they do, do less well with treatment
 A mood disorder may be the first presentation of a dementia
 Depression needs to be separately sought and treated

19

What is Wernicke-Korsakoff's syndrome?

Wernicke’s encephalopathy- delirium with ophthalmoplegia
Korsakoff’s psychosis- amnesic/confabulatory disorder
Thiamine deficiency: alcoholics, malnourished people

20

What investigations do doctors perform?

• FBC, U and E’s, creat, LFT’s, + B12, TSH, Ca: consider CO level
• CXR
• ConsiderVDRL,HIVtest
• CT or MRI head scan unless clinically like Alzheimer's and already quite advanced
• EEG if dementia’s going quickly and/or there is myoclonus, or if you suspect superimposed complex partial seizures
• LP if blood serology for syphilis is +ive, or if there’s any suspicion of immunosuppression

21

When does dementia progress really quickly and how is this diagnosed?

• Possible mass lesion [CT/MRI]
• Infective cause (TB,abcess,HIV) [CT/MRI & LP]
• Creutzfeld-Jakob disease [EEG, LP]
• Metabolic problem [Blood tests]

22

What's the management for dementia?

• Drugs-for cognitive, behavioural and psychiatric problems associated with Alzheimers and Lewy Body disease
– Cholinesterase inhibitors, donepezil, galantamine, rivastigmine (primary and secondary co-management)
– Memantine, research trials only – Psychotropic drugs
• Vascular dementia-manage risk factors, antiplatelet, cholesterol lowering medications, BP reduction,
• Non-drug management-community support, carer support, respite care, case management

23

What is delirium?

Delirium is a condition that: develops quickly (usually over hours or days)
involves changes in consciousness and attention, cognition (thinking and reasoning), and perception
characteristically fluctuates over the course of the day
represents a sudden and significant decline from the previous level of functioning
is usually temporary and reversible and does not reflect a persistent psychiatric disorder
carries a high mortality

24

What are the risk factors of delirium?

• Age (more likely with increasing age) • Pre-existing cognitive deficit • Psychiatric illness • Severe physical co-morbidity • Previous episode of delirium • Deficits in hearing or vision (strongly associated with delirium)
• Chronic anticholinergic drug use • A new environment and stress

25

What are the symptoms of delirium?

Consciousness: Clouded or alert: distractible: irritable/emotional
Memory: Usually disorientated and with STM problems
Sleep: Commonly have sleep/wake reversal
Distorted perception:
Visual hallucinations and mis-perceptions very common These can be mildly persecutory and are often threatening
Activity: Both hyperactive/restless and apathetic/lethargic forms Language and praxis
Language difficulty and dyspraxia are common

26

What are the common precipitants of delirium?

Any acute illness and many medications can cause delirium.
Drugs (particularly those with anticholinergic side effects Drug withdrawal (including alcohol, benzodiazepines, SSRIs)
Infections (e.g. pneumonia, UTI, septicaemia) Neurological (e.g. stroke, subdurals,, epilepsy) Cardiological (e.g. myocardial infarction, heart failure) Respiratory (e.g. pulmonary embolus, hypoxia from any cause)
Electrolyte imbalance (e.g. dehydration, renal failure)
Endocrine & metabolic illnesses.

27

When should drugs be used?

Wandering and disorientation are NOT indications for drug treatment of delirium.
There is no drug that makes a wandering patient sit by their bed.
Drugs are not free from side effects; drugs that sedate may reduce agitation but increase cognitive impairment and the risk of falls.
Consider in who’s interest this sedation is
Lorazepam 0.5mg orally is one of the least bad options: - wait 30 minutes before deciding the dose is not enough - should not give more than 2mg in a day without getting advice - it can also be given s/c or im if required (n.b. diazepam cannot)
Haloperidol isn’t very good: the effect is commonly delayed and the patient is doped all the next day. Keep the dose down: 1mg.

28

What are some examples of behavioural methods to minimise delirium?

Communicate clearly and concisely; Give repeated verbal reminders of the (day, time, location, and
identity of key individuals) Provide clear signposts to patient’s location including a clock, calendar Have familiar objects from the patient’s home in the room Try to ensure consistency in staff Use television/radio/music for relaxation Involve family and caregivers to encourage feelings’ of security and
orientation Reduce fear and anxiety; approach and handle the patient carefully Avoid transfers between and within wards as much as possible
Try to reduce the amount of noise and fuss Ensure that lighting is adequate; provide a 40-60 W night light Fix glasses/hearing aids Encourage self care and participation in treatment Keep mobile/hydrated

29

What's some general info good for dentists?

• Dementia very common in older people and frequently not diagnosed
• Self neglect (especially teeth) very common
• You will need a collateral history-GP, relative, neighbour
• Always encourage patient with dementia to be seen with spouse/relative/carer
• Accurate Drug History vital-again primary care history essential – Remember Warfarin/aspirin/ clopidogrel
• Capacity issues/informed consent-always consider
• Remember some people have very good social facade, always check orientation to day, date, month, year, place, and personhood – if disorientated to time you will not get an accurate history of preceeding events
• Often older frail people with dementia don’t eat
• May have extensive candida (easily treatable with systemic fluconazole and nystatin (for the dentures)
• Delirium commonly caused by infected caries in teeth