Dementia and delirium Flashcards
(54 cards)
1
Q
What is cognition?
A
- Attention/orientation
- Memory
- Executive functioning
- Language
- Calculation
- Praxis
- Visuospatial ability
2
Q
What are the different types of attention?
A
- Arousal
- Sustained attention
- Divided attention
- Selective attention
3
Q
What part of the brain is involved in attention?
A
- Attentional function is distributed
- Reticular activating system (RAS)
- Cortical association areas
- Multiple neurotransmitter systems involved
4
Q
What are abnormalities in attention a hallmark of?
A
Delirium
5
Q
How are deficits in attention tested?
A
- Observe the patient
- Specific tests:
- Orientation in time and place (also depends on episodic memory)
- Digit span-forward/backward (also depends on working memory)
- Reciting months of the year (or days of the week) backwards
- Serial 7s
- Spell WORLD backwards
- The STROOP Test
6
Q
What is the stroop test?
A
Colours are spelt out on paper in a different coloured ink.
Patient is asked to say the colour the word is written in rather than the colour the word spells.
7
Q
What is retrograde amnesia?
A
Amnesia of memories prior to the disease or injury
8
Q
What is anterograde amnesia?
A
Amnesia of memories after the disease of injury
9
Q
What functions does the frontal lobe have?
A
- goal setting and motivation
- judgement control of inhibition
- flexibility and problem solving
- planning/sequencing organisation
- abstract reasoning
- social behaviour personality
10
Q
Where is the language centre in the brain?
A
Left hemisphere (in most people)
11
Q
What are common disorders of the language centre?
A
- aphasia
- agraphia
- alexia
- nominal dysphasia
- wernicke’s aphasia
- Broca’s aphasia
12
Q
Aphasia:
A
an impairment of language, affecting the production or comprehension of speech and the ability to read or write
13
Q
Agraphia:
A
an acquired neurological disorder causing a loss in the ability to communicate through writing, either due to some form of motor dysfunction or an inability to spell
14
Q
Alexia:
A
loss of the ability to read due to cerebral disorder
15
Q
Describe Wernicke’s aphasia
A
- Fluent
- Phonemic and semantic paraphasia
- Comprehension impaired
- Wernicke’s area (temporal lobe)
16
Q
Describe Broca’s aphasia
A
- Non-fluent
- Agrammatic
- Phonemic paraphasias common
- Broca’s area (inferior frontal lobe)
17
Q
Where is the calculation centre of the brain?
A
The angular gyrus in the parietal lobe is crucial and the left hemisphere is generally important
18
Q
acalculia:
A
- inability to comprehend or write numbers properly
19
Q
Anarithmetria:
A
difficulty with arithmetic
20
Q
Dyspraxia:
A
Disorder causing difficulty in activities requiring coordination and movement
21
Q
Which area of the brain is important for coordination and movement?
A
usually left hemisphere function - parietal and fontal lobe
22
Q
How can deficits of praxis be classified?
A
- Errors of :
- Action conception (knowledge of actions/item function)
- Action production (production/control of movement)
23
Q
How is apraxia/dyspraxia described?
A
by region and description of the deficit • Ideational apraxia • Imitation of gestures • Orobuccal movements • Use of imagined objects • Lower limb apraxia
24
Q
Where does the visual cortex feed into?
A
the parietal lobe and the temporal lobe
25
What are common problems associated with visuospatial deficits?
* Topographical disorientation
* Difficulties with dressing (dressing apraxia)
* Mis-reaching for objects
* Visual neglect
* Visual object agnosia
* Prosopagnosia
26
What is dressing apraxia
Inability to dress due to patient's deficient knowledge of the spatial relations of his or her body
NB: although called apraxia - this is not to do with coordination of movement, but a visualspatial deficit!!
27
Prosopagnosia
Disorder characterized by the inability to recognize faces
28
How can constructural dyspraxia be tested in the clinical setting?
Part of the mini mental state exam - ask a patient to copy either a 3D cube or two pentagons overlapping
29
What is dementia?
Syndrome with chronic, progressive (usually irreversible) cognitive
impairment due to brain disease
30
What are the general clinical features?
* Deterioration from higher level of function
* Multiple cognitive deficits
* Chronic duration > 6 months
* Impact on social/occupational function
* Personality change/disintegration
* Decline in emotional control/motivation
* No clouding of consciousness (exclude delirium)
31
Describe the spectrum of cognitive impairment
Age related decline > Mild cognitive impairment (MCI) > dementia
32
Describe the epidemiology of Dementia
65+ population prevalence of dementia is 7.1%
Equals one in every 79 (1.3%) of entire UK population
• 1 in every 14 of the population aged 65 years and over
850,000 people with dementia in 2015
40,000 people have early-onset dementia
33
What is the cost of dementia on society?
• Total cost to society £26.3 billion
34
List some causes of degenerative dementia
- alzeimers disease
- vascular dementia
- fronto-temporal dementia
- parkinson's disease
- huntington's disease
- wilson's disease
- MS
- PSP
35
List some causes of intracranial dementia
- tumour
- head injury
- SDH
- CVA
- NPH
36
List some causes of infections that cause dementia
- CJD (prion disease)
- neurosyphilis
- HIV associated dementia
- TB
37
List some endocrine causes of dementia
- hypothyroidism
- hyperparathyroidism
- cushing's
- addisons
38
List some metabolic causes of dementia
- uraemia
- hepatic encephalopathy
- hypoglycaemia
- hypo/hypercalcaemia
- hyper/hypomagnesiamia
39
list the vitamin deficiencies that can cause dementia
- B12
- Folate
- Thiamine
- Niacin
40
List the toxins that can cause dementia
- Alcohol
| - Lead
41
What are the main psychiatric differentials of dementia
- normal ageing
- delirium
- mild cognitive impairment
- amnesiac syndromes
- chronic brain damage (e.g. head injury or anoxia)
- depression (pseudo-dementia)
- Late onset schizophrenia or other psychosis
- Learning disability
- malingering presentations
- dissociation
42
How is dementia diagnosed?
* Clinical assessment
* Corroborative history
* General physical examination
* Mental State Examination
* Standard (+/- specialised) bloods
* Structured cognitive testing
* Structural (+/- functional) imaging
43
What investigations are required before diagnosing dementia?
* FBC
* ESR, CRP
* Glucose
* U+E
* LFTs
* Bone profile
* TFTs
* Urinalysis, MSSU
* B12, folate
* Consider HIV and syphilis serology
* CXR
* LP
* ECG
* CT/MRI
* SPECT (includes dopamine FP-CIT)
* EEG
44
What tests can be performed to test cognition?
* Addenbrooke’s Cognitive Examination (ACE)
| * MMSE (Mini-Mental State Examination)
45
Describe Addenbrooke’s Cognitive Examination (ACE)
* 100 point test
* More sensitive than MMSE in early disease
* Covers executive function
* More detailed, broader assessment of cognition than MMSE
* More time consuming to administer
* Two cut off scores 88 and 82
46
Describe the MMSE (Mini-Mental State Examination)
* Ease and speed of administration
* High inter-rater reliability
* Insensitive to early impairments eg mild cognitive impairment (MCI)
* Poorly covers executive function. Weighted heavily towards memory/attention.
* Influenced by age, education, socio-economic status
* Screening tool and good for monitoring change
47
What causes of dementia are reversible?
* B12, folate deficiency
* Hypothyroidism
* Hydrocephalus, subdural haematoma, CNS tumour
* Wilson’s disease
* Cerebral vasculitis
* Depression ‘pseudo-dementia’
* Whipple’s disease
* Metabolic problems
48
What are the hallmark features of delirium?
* Impaired consciousness
* Hyperactive or hypoactive sub-type
* Acute onset
* Change in cognition
* Cognitive deficits
* Visual hallucinations (and other psychotic symptoms)
* Sleep-wake cycle disruption
* Affect changes
* In most cases, evidence of an underlying direct cause
49
What is delirium?
Acute neuropsychiatric syndrome
50
What is the importance of delirium?
• 15-30% of hospital inpatients aged over 65
•At least 10% of unselected UK admissions in general
hospital
• 15% of older adults develop delirium during
inpatient stay
•Under-recognised in 2/3 of cases
•A wide range of complications – prevention is key
51
Give a simplistic overview of the aetiology of delirium
predisposing factors + precipitating factors = delirium
52
Give examples of precipitating factors that can result in delerium?
* Infection
* Stroke
* Drugs
* MI
* Fractures
* Cancer
* Electrolyte /fluid balance problems
* Heart failure
* Diabetes
* PVD
* Alcohol withdrawal
53
What are the non-pharmacological approaches to delirium
• Noise control and lighting
• Orientating influences – calendars, clocks, familiar objects, family (reality
orientation)
• Fluid balance/diet/bowel habit/pain control
• Regular communication/reassurance from staff. Address sensory impairment
• Limit variation in staff
• Encourage normal sleep cycle and side room if possible
• Early mobilising
• Avoid ward transfers
• Consider necessity of certain procedures
• Recognise frailty
54
What are the pharmacological treatments used in delirium?
Antipsychotics:
- haloperidol
- olanzapine
- risperidone
- aripiprazole
- quetiapine
Benzodiazepines:
- lorazepam
- diazepam
Others:
- melatonin
- trazodone
- specific treatment of underlying cause
