Dementia/delirium

Question 1

What is cognitive impairment?

Answer 1

Disturbance of higher cortical functions,
including memory, thinking, judgement, language, perception and awareness

Cognitive impairments may be single or multiple and may be static or progressive

It is not a specific illness but description of someones condition

Question 2

What is dementia?

Answer 2

Cognitive impairement with decline in both memory and thinking which is sufficient enough to impair personal activities of daily living

Problems with the processing of incoming information (problems with maintaining and directing information)

CLEAR CONSCIOUSNESS

Above syndrome will be present for more than or equal to 6 months

Question 3

What is delirium?

Answer 3

Impairement of cognition- disturbances of attention and conscious level; abnormal psychomotornbehaviour and affect, disturbed sleep- wake cycle

Onset is usually acute (hours/days)

All symptoms fluctuate during the daytime and are typically worse at night

2 SUBTYPES- hyperactive and hypoactive (easily overlooked 😟)

Hypoactive is the most common type

Question 4

What does the inverse care law mean?

Answer 4

In someone with dementia, the more their disease progresses they become more dependent and vulnerable but also become less aware of their disabilities

Question 5

What causes dementia?

Answer 5

Dementia is a syndrome, a range of diseases may cause it…

• alzheimers disease
• vascular dementia
• alcoholic
• dementia with lewy bodies
• frontotemporal dementia
• huntingtons disease

Question 6

What are the early stage features of dementia?

Answer 6

Forgetfulness and other memory symptoms (most prominent cognitive abnormality, especially in Alzheimers disease)

There may be subtle changes in mood and behaviour- loss of motivation and interest

There may be minimal intrusion into day to day functions at the start ie: financial

Question 7

What are the mid stage features of dementia?

Answer 7

Memory problems become more prominent and other cognitive difficulties may start to emerge

Behaviour becomes more marked

Disability becomes more obvious and they will need frequent support but not continous support and assistance

Often their awareness of disability starts to diverge from reality

Question 8

What features are in the late stage of dementia?

Answer 8

Severe and pervasive memory problems accompany other major cognitive disabilities- severe disorientation, failure to recognise familiar people

Marked (+ve and -ve) changes in behaviour- agitation, restlessness, irritability, disinhibition, severe apathy

Disability is severe and even basic aspects of personal functioning snd failing, people require more or less continous supervision

Question 9

What are the differentials for dementia?

Answer 9

hypothyroidism, Addison's
B12/folate/thiamine deficiency
syphilis
brain tumour
normal pressure hydrocephalus
subdural haematoma
depression
chronic drug use e.g. Alcohol, barbiturates

Question 10

What is vascular dementia?

Answer 10

Vascular dementia (VD) is the second most common form of dementia after Alzheimer disease. It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease. Vascular dementia has been increasingly recognised as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment (VCI). Early detection and an accurate diagnosis are important in the prevention of vascular dementia.

Question 11

What are the risk factors of vascular dementia?

Answer 11

History of stroke or transient ischaemic attack (TIA)
Atrial fibrillation
Hypertension
Diabetes mellitus
Hyperlipidaemia
Smoking
Obesity
Coronary heart disease
A family history of stroke or cardiovascular

Question 12

What do patients with vascular dementia present with?

Answer 12

Several months or several years of a history of a sudden or stepwise deterioration of cognitive function

Symptoms and speed of progression vary, but may include..

• focal neurological abnormalities (visual disturbance, sensory or motor symptoms)
• difficulty with attention and concentration
• seizures
• memory disturbance
• gait disturbance
• speech disturbance
• emotional disturbance

Question 13

What may you see on an MRI of someone with vascular dementia?

Answer 13

May show infarcts and extensive white matter changes

Question 14

What are the features of lewy body dementia?

Answer 14

In contrast to Alzheimers, early impairements in attention and executive function rather than just memory loss

Cognition may be fluctuating, in contrast to other forms of dementia

Usually develops before parkinsonism

Parkinsonism

Visual hallucinations (delusions and non visual hallucinations may also be seen)

Question 15

How do you assess a patient with suspected dementia, in terms of history and examination…

Answer 15

Diagnostic assesment is a 2 stage process…

Firstly you diagnose the syndrome and then you diagnose the disease

History…

What is the course of the symptoms over time?
This is the most important bit of diagnostic information and the patient probably won’t be able to tell you

Is there any evidence of disability or impact on the day to day life?

Why have they come now? Has anything happened recently?

Any changes in the general health?

Examination

Cognitive screening assessment- GPCOG, AMT, 6-CIT, MMSE, MOCA etc….
Check for new physical findings if prompted by hx
(Neurological or cardiovascular)

Question 16

What investigation do you do for suspected dementia?

Answer 16

‘Dementia screen’ bloods (these are not actually screening for dementia but screening for other things that may be contributing to the dementia)
FBC, LFTS

Structural brain imaging- CT/ MRI

Functional brain imaging- perfusion, glucose metabolism, dopamine transporter turnover (not routinely done)

Specialised tests for special situations with unusual disease like prion disease (EEG, lumbar puncture)

Question 17

How do you manage dementia?

Answer 17

For all patients- give information and explanation
Give psychological support- maintaining a positive outlook and remaining engaged in life
Practical advice to cope with cognitive problems +/- assistive technologies
Carer support

For some types of dementia there are drug treatments

Question 18

What drugs can be given to patients with alzheimers disease?

Answer 18

Cholinesterase inhibitors
Donepezil, rivastigmine, galantamine

NDMA receptor antagonists
Memantine

Question 19

What can you give for parkinsons disease dementia/ DLB?

Answer 19

Rivastigmine

Question 20

How does memantine work?

Answer 20

Predicated on the glutamate overactivity hypothesis in AD

Blocks NDMA receptors which glutamate usually bind tl

Question 21

What drugs should you avoid in patients with dementia?

Answer 21

Avoid anticholinergics- these can cause cognitive deterioration, hallucinations and other psychotic symptoms

Benzodiazepines- use sparingly due to the risk of falls, cognitive decline etc

Antipsychotic tranquilisers- avoid where possible due to risks of stroke, falls, movement disorders and cognitive deterioration

Question 22

What are the risk factors for delirium?

Answer 22

Pre existing cognitive impairment 
Fracture on admission 
Age over 80 
Illness severity 
Age over 65 
Infection 
Vision impairment

Question 23

What drugs can induce delirium?

Answer 23

Psychiatric drugs- antidepressants, antipsychotics, benzos

Anti parkinsonian

Anticholinergic

Opiates

Diuretics

Recreational drug intoxication and withdrawal

Question 24

Give examples of drugs with anticholinergic properties which can cause delirium in older patients…

Answer 24

Antihistamine- hydroxyzine, diphenyhdramine
Antisasmodic- alverine, hyoscyamine 
TCAs- Amitriptyline 
Lorazepam 
Codeine
Anti arrthymic- digoxin 
Diuretic- furosemide 
Antiparkinsonian 
Bladder stabliser- oxybutnin 
Bronchodilator- theophylline

Question 25

What screening tools can be used in delirium?

Answer 25

CAM score | THINK delirium

Question 26

What is the immediate actions when you think someone has delirium?

Answer 26

Focused history and examination Collateral history (GPs/relatives/carers) Identify and treat the underlying causes Refer to UHL sepsis if suspecting sepsis Complete the ‘know me better’ profile with carers Cognitive assessment with AMT 10/ MMSE Perform medication review using STOPP/START Heighten the patients level of supervision and position patient in a high visibility bed if available Update and involve relatives and carers with provide UHL delirium leaflet Refer to FOPAL for complex and challenging patients only (frail older persons advice and liaison)

Question 27

What does THINKDELIRIUM stand for?

Answer 27

``` T= trauma (head injury, intracranial event) H= hypoxia (PE, CCF, MI, COPD, pneumonia) I= increasing age/frailty N= neck of femur fracture K= smoKer (or alcohol withdrawal) D= drugs E= environment (movement on different wards) L= lack of sleep I= imabalanced e-s (renal failure, Na+, Ca2+, glucose, liver function) R= retention (urinary or constipation) I= infection/sepsis U= uncontrolled pain M= medical conditions like dementia and parkinsons disease ```

Question 28

How do you treat delirium?

Answer 28

Treat the underlying cause and exacerbating factors Provide personalised care Manage pain (may not be able to tell you, look for winching) Rationalise meds Re orientate pts Ensure the environment is well lit and minimise excessive stimulus where possible Involve family and carers where appropriate Ensure patients have earing aids, contact lenses Encourage oral intake Communicate clearly to patients- reassure and repeat Enable good sleep Manage constipation Mobilise the patient

Question 29

What are the key features of delirium?

Answer 29

``` Acute onset Fluctuates Altered level of consciousness Cognitive decline Inattention Behavioural and psychological disturbances Hypo or hyperactive ```

Question 30

What are the most common MH problems in older adults in hospital?

Answer 30

The 3Ds | Dementia, delirium, depression

Question 31

Why is delirium improtant?

Answer 31

Delirium is associated with poorer patient outcomes… - increased length of stay in hospital - increased mortality rates - increased hospital re admissions - increased chance of needing 24hr care on discharge - higher correlation between people who suffer delirium who go on to develop dementia

Question 32

How can you assess a patient with delirium?

Answer 32

Clarify the patients baselines- a patient hx/ collateral is one of the most important tools You need to check for reversible causes Complete bloods- U and Es, FBC, LFT, calcium, glucose, CRP Check bowels (constipation) Physical observations (temp, signs of infection, O2 sats in an acceptable range?) Mid stream urine sample Review the patients drug history- have any meds been stopped or started ? CT head to rule out potential acute intracranial changes Others guided by hx CXR, lumbar puncture, MRI, EEG (seizures/ encephalitis), ABG

Question 33

What are the important delirium screening tools?

Answer 33

SQiD Single question in delirium, this is what it says on the tin, it is basically when you ask someone that knows the patient whether they have been more confused in the past 3 days Confusion assessment method 4 questions Is there an acute onset with fluctuating course Is the patient inattentive Is there evidence of disorganised thinking Are there altered levels of consciousness? 4AT (4 or more= delirium present) 6CIT (much quicker delirium screening), higher the score the worse the patient Longer like the MOCA, MMSE, or ACE not appropriate as they take too long

Question 34

What pharmacological management can be given to delirium?

Answer 34

Haloperidol 0.5-1 mg in elderly aim for a max of 2mg in 24hrs However do not use haloperidol in patients with a background of parkinsons or lewy body dementia Therefore you can give lorazepam (0.5-1mg)

Question 35

Why should you not give antipsychotics with haloperidol?

Answer 35

There is a risk of QTc prolongation!

Question 36

What are hyperactive and hypoactive often misdiagnosed as?

Answer 36

Hyperactive- acute psychosis | Hypoactive- depression

Question 37

What are the shared/ opposing features of delirium or depression?

Answer 37

Delirium- perceptual disorder, FLUCtUATING, clouding consciousness, disordered attention Depression- pervasive unhappiness, anhedonia, negative thought content, suicidal thoughts Both- anergia, reduced motivation, reduced activity levels, impaired oral intake, abnormal sleep

Question 38

What is a memory clinic/service?

Answer 38

Defined as a MDT that assesses and diagnoses dementia, and may provide psychosocial interventions for dementia

Question 39

Why is early diagnosis of dementia important?

Answer 39

Allows medical management to be optimised Risk reduction Allows access to care and services Relief gained by knowing there is something going on, reduces blame and impatience Maximises the patients decision making while they still have capacity

Question 40

How can you break the diagnosis of dementia well?

Answer 40

``` Involve family Prepare Explore the patients perspective Disclosure of diagnosis Responding to patients reaction Focus on QoL Future planning Effective communicaton ```

Question 41

What are two tools useful for identifying delirium?

Answer 41

CAM | 4AT