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3a psychiatry > Dementia/ delirium > Flashcards

Dementia/ delirium Flashcards

1
Q

Define “delirium”

A

an acute, transient and reversible state of confusion and cognitive impairment associated with behavioural abnormalities

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2
Q

List some of the causes of delirium

A

D - drugs e.g. benzodiazepines, opioids, anti convulsants
E- electrolyte imbalance e.g. hyper/hypo calcaemia
L-lack of drug (withdrawal) e.g. alcohol withdrawal
I- infection e.g. sepsis, UTI, encephalitis, meningitis, pneumonia
R- reduced sensory e.g. blind, deaf
I- intracranial e.g. haemorrhage, epilepsy, tumour
U- urinary retention, constipation
M- malnutrition e.g. thiamine, B12, folate deficiency

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3
Q

Who are at high risk of having delirium?

A 
elderly 
people with diffuse brain disease e.g. Alzheimers, parkinson 
patients with hip fractures
severely ill
deaf/ blind patients
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4
Q

What are the ICD-10 requirements for a diagnosis of delirium?

A
  1. impaired consciousness and attention
  2. perceptual disturbance - visual hallucinations and delusions
  3. cognitive disturbance - decreased concentration, disorientation, short term memory loss, distracted
  4. developed over a short period of time and fluctuates - worse at night (sundowning), lasts up to 6 weeks
  5. evidence it is related to a physical cause
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5
Q

What are the 2 types of delirium?

A
  1. hyperactive - restless, agitated, shouting and loud

2. hypoactive - withdrawn, picking at clothes, quiet, sleeping

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6
Q

What investigations should be carried out if suspecting delirium?

A
  1. informant history
  2. mental state examination
  3. physical examination
  4. blood investigations - FBC, ESR, U&E, LFT, calcium, glucose
  5. MSU
  6. CXR
  7. CT/MRI
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7
Q

What are the differences between delirium and dementia?

A

delirium rapid deterioration and fluctuating / dementia slow deterioration and slowly progressive

delirium consciousness clouded but dementia alert

attention impaired in delirium but not in dementia

delirium reversible and dementia not

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8
Q

How can delirium be prevented?

A
  1. maximise orientation
    clocks, calendar, appropriate lighting, staff explain gin regularly who/where they are
  2. prevent causes of delirium
    decrease polypharmacy, reduce constipation and retention, reduce infection (avoid catheters!)
  3. promote well being
    encourage mobilisation, good pain control, sleep, activities and social interaction
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9
Q

How is delirium managed?

A
  1. find the CAUSE and treat!
  2. manage on general hospital ward
  3. imply preventative measures
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10
Q

How is a distressed/agitated delirious patient managed?

A

short term antipsychotic e.g. haloperidol IM/IV
OR
short term benzodiazepines e.g. lorazepam

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11
Q

Define “dementia”

A

decline in higher cortical function that is chronic, progressive, irreversible and needs 6 months decline of function

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12
Q

List some of the subtypes of dementia

A 
alzheimers 
vascular
lewy body 
fronto temporal (picks disease)
parkinosns
huntingtons 
normal pressure hydrocephalus
creutzfeldy Jacob disease
Alcohol induced
HIV
wilsons disease
neurosyphilis
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13
Q

How is dementia classified?

A

CORTICAL DEMENTIA: affects cerebral cortex -> causes memory impairment, dysphasia, visuospatial impairment, problem solving deficits

SUBCORTICAL DEMENTIA: affects basal ganglia and thalamus -> psychomotor slowing, depression, personality change, language preserved

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14
Q

What are the key features of dementia?

A

memory problem/ cognitive deficits
global
progressive
affecting function and activities of daily living

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15
Q

What are the behavioural and psychological symptoms of dementia?

A 
anxiety
depression
agitation
psychosis 
disinhibition
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16
Q

What is included in a confusion screen?

A 
FBC - low WCC = confusion
U&E - dehydration = confusion, hyponatraemia = memory loss
LFTs
glucose
calcium - hypercalcaemia = confusion
TSH
B12/folate
17
Q

List the types of cognitive state examinations

A
  1. mini mental state examination
  2. six item cognitive impairment test - most common in GP
  3. abbreviated mental test - most used in hospital
  4. MOCA - used more commonly
  5. Addenbrooks - culturally/language dependent
18
Q

What are some of the risk factors for alzheimers disease?

A 
genetic - ApoE gene 
females
downs syndrome
hypothyroidism
previous head injury
19
Q

Describe the pathology of alzheimers disease?

A
  1. atrophy of brain
  2. enlarged ventricles
  3. neuronal loss
  4. build up amyloid plaques and neurofibrillary tangles in hippocampus and cerebral cortex
20
Q

What are the key clinical features of alzheimers disease?

A

steady, gradual decline

global memory loss

21
Q

What are the 4 cognitive A’s of alzheimers?

A

Amnesia - recent memory disorientation
Apraxia - clothes, using appropriate cutlery
Agnosia - failure to recognise parts of the body
Aphasia - mixture of repetitive and expressive speech

22
Q

How is Alzheimers disease managed?

A
  1. NMDA receptor antagonist e.g. memantine
    OR
  2. acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine
23
Q

What is the mechanism of NMDA receptor antagonists and their side effects?

A

e.g. memantine

inhibitor of glutamate NMDA receptors
improves learning and memory

SE: diarrhoea, insomnia, dizziness, headache

24
Q

What is the mechanism of acetylcholinesterase inhibitors and their side effects?

A

e.g. donepezil, rivastigmine, galantamine

inhibitors of intra synaptic breakdown of acetylcholine therefore increasing cholinergic transmission in the brain

SE: GI, heart block

25
Q

What are the risk factors for vascular dementia?

A 
hypertension
hypercholesterolaemia
diabetes 
peripheral vascular disease
TIA and stroke
family history 
sickle cell anaemia 
smoking
sedentary lifestyle
26
Q

What are the key features of vascular dementia?

A

stepwise deterioration
onset and progression acute
emotional changes/ personality change

27
Q

What is the treatment for vascular dementia?

A

AIM= reduce risk factors for vascular dementia

statins
aspirin
anti hypertensive medication

28
Q

What are the key features of fronto temporal dementia?

A

also called picks disease

very aggressive form of dementia
a lot younger onset
personality change (affects frontal lobe)
intellectual sparing 
gradual progression
29
Q

What is the pathology changes in lewy body dementia?

A

presence of lewy bodies (made of alpha synuclein protein) in basal ganglia and cerebral cortex

decrease in acetylcholine transmission in neocortex

30
Q

What are the clinical features of lewy body dementia?

A

fluctuating onset of cognition and alertness
rapid decline
visual, vivid hallucinations
parkinsonian signs e.g. bradykinesia, limb rigid, gait disorder

31
Q

How is lewy body dementia diagnosed?

A

DAT scan (dopamine transported)

32
Q

How is lewy body dementia managed?

A

Rivastigmine improves symptoms

NEVER GIVE ANTIPSYCHOTICS as aggravates parkinsonian signs which increases risk of neuroleptic malignancy

33
Q

What are the key features of Creutzfeldt Jacob disease?

A

rapid decline
fatal and aggressive
cerebellar and extra pyramidal signs
PRION PROTEINS THROUGHOUT THE BRAIN

34
Q

how is fronto-temporal dementia diagnosed?

A

SPECT scan - knife blade atrophy

35
Q

what are the symptoms of normal pressure hydrocephalus?

A
  1. urinary incontinence
  2. wide base gait
  3. dementia - confusion, apathy, mental slowness

3a psychiatry (9 decks)

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