1
Q
What are the causes of confusion in elderly?
*remember 4D 1M
A
- Deliruim
- Depression
- Dementia
- Drugs
- Metabolism
- hypothyroidism
- hypercalcaemia
- vit B12 def
- hydrocephlus
2
Q
What is Dementia?
A
- Decline in higher cortical function
- Imparied memory, intellect, personality
3
Q
What are the two types of dementia based on onset?
A
- Early onset - <65
- Late onset - >65
4
Q
What are the 5 types of dementia?
*remember FLAVPM
A
- Frontal lobe dementia (2nd common cause of early onset)
- Lewi Body dementia
- Alzheimer’s dementia (1st common)
- Vascular dementia (2nd common)
- Parkinson’s disease c demnetia
- Mixed dementia (A+V)
5
Q
What are the macroscopic changes in AD?
A
- global atrophy
- sulcus widening
- enlarged 3rd & 4th interventricular space
6
Q
What are the microscopic features of AD?
A
- senile amyloid plaques (around neurones)
- neurofibrillary tau tangles (inside neurones)
7
Q
What causes the deposition of amyloid?
A
- mutated Amyloid Precursor Protein (APP) and B-secretase enzyme
- Incomplete breakdown of APP
- amyloid deposition occur
8
Q
What are the causes of AD?
A
- Early onset
- B-APP
- Presenilin 1
- Presenilin 2
- Late onset
- Apolipoprotein E gene
9
Q
What are the Sx for AD?
A
- decline memory
- decline spatial navigation
- decline executive function
10
Q
Which genetic disorder is at high risk of developing AD and why?
A
- Downs Syndrome
- APP gene located on chromosome 21
11
Q
What cognitive assessments can you perform for dementia pt?
A
- Mini Mental State Examination (MMS)
- Abbreviated Mental Test (AMT)
- 6 item cognitive impairment test (6-CIT)
- General Practitioner Assessment of Cognition (GPCOG)
- 7 Minute Screen (7MS)
12
Q
What are the reversible causes of dementia?
A
- alcohol dependence
- hypothyroidism
- vit b12 def
- syphilis
- normal pressure hydrocephalus (NPH)
13
Q
What are the 3 phases of AD?
A
- Asymptomatic phase
- changes at tissue level
- no sx
- Predementia phase
- memory starts to decline
- daily functioning not affected
- Dementia phase
- significant memory loss
- daily functioning affected
14
Q
What Ix can you order for AD?
A
- Bedside
- MCA/MMS
- Imaging - show cortical atrophy
- CT
- MRI
- Fluorodeoxyglucose (FDG) PET Scan
- Special test
- Brain biopsy (definitive dx) *only performed during autopsy
15
Q
A
16
Q
How would you Mx AD?
A
- AChE inh
- Donepezil (first line)
- Galantamine
- Rivastigmine
- NMDA RA - Glutamate inh
- Memantine (second line)
- SSRI
- Doxepin
- Amitryptilin
- Risperidone
17
Q
What are the side effects of AChE inh?
A
- Diarrhoea
- Vomiting
- syncope
- bradycardia
- heart block
18
Q
Glutamate is an excitatory neurotransmitter for learning and memory. Why give Memantine for AD?
A
- in AD - too much glutamate
- overexcitation of cells
- high Ca in cells
- cell death
19
Q
What is the Px of Lewi body dementia?
A
- Misfolding of alpha-synuclein protein
- Aggregation - form lewi body in substantia nigra, temporal lobe, frontal lobe, cingulate gyrus
20
Q
What are the Sx for LBD?
*remember haLEWYcinations
A
- visual/auditory hallucinations
- fluctuating, episodic deficits of attention and alertness
- parkinsonism (TRAP)
- tremor
- rigidity
- Akinesia
- postural instability
21
Q
How would you Mx LBD?
A
- same as AD
- avoid antipsychotics for hallucinations - can worsen parkinsonism
- LEVADOPA - but weigh with risk of developing delirium
22
Q
A
23
Q
What are the RF for vascular dementia?
A
- HTN
- DM
- coronary artery disease
- smoking
24
Q
What type of stroke is vascular dementia associated with?
A
Multi-infarct dementia
25
Lacunar stroke is seen in VD. What arteries are affected?
* lenticulostriate arteries - branch of MMA
26
What pattern of cognitive deterioration is demonstrated in VD?
* Stepwise deterioration
* AD is gradual decline
27
What are the Sx for VD?
* urinary incontinence
* cranial nerve palsy
* focal neurological deficit
* late -onset memory loss
28
How would you Mx VD?
* Lifestyle changes - aim to prevent another stroke from happening
* control HTN/DM/Cholesterol
* Pharmacology
* \*same as AD
29
What is the Px of frontotemporal lobe dementia?
1. Atrophy of fontal and temporal lobes
30
What are the Sx for FTD?
Present \<65
* Early onset of personality & behavioral changes
* aphasia
31
What is FTD also known as?
Pick's disease
32
33
What is the difference between Parkinson's disease dementia and Lewi body dementia?
* Sequence of events
* PDD
* TRAP and then dementia
* LBD
* dementia and then TRAP
34
What is Delirium?
* Acute, sudden onset confusion with fluctuating course
* Develops over 1-2 days
35
What are the causes of delirium?
\*remember DELIRIUM
* Drug toxicity
* withdrawal: alcohol, benzos, cocaine, coffee
* (see other flash cards)
* Endocrine
* hyper/hypo thyroidism
* addisons
* cushing's
* Liver failure - NH3 build up in blood
* Intracranial
* stroke
* haemorrhage
* abcess
* epilepsy
* Renal failure
* Infections
* pneumonia, UTI, sepsis, meningitis
* Urinary retention
* Metabolic
* hypoxia
* electrolyte imbalance
36
What drug toxicity can cause delirium?
* anticholinergics
* anti histamines
* beta-blockers
* corticosteroids
* calcineurin inh.
* dopamine agonist
* levodopa
* monoamine oxidase inh
* opiates
* tricyclic antidepressant
37
What are the Sx of Delirium?
* hyperactivity and agitation or hypoactivity and drowsiness
* inattention/difficulty focusing
* +/- disorientation
* illusions, delusion, hallucination
* sleep disturbances
* hypersensitivity to light and sound
38
39
What are the features of delirium sx?
* hours to days
* fluctuates in a day
* worsens at niight
40
How would you diagnose delirium?
* Clinically
* Acute illness + confusion (x explained by another neuropsychiatric syndrome)
* Bedside
* DSM V
* Confusion Assessment Method (CAM)
41
What are the RF for delirium?
* 65 or older
* sensory impairment
* cognitive impairement
* surgery
* current hip fracture
* severe infections
42
What Ix would you order for delirium?
* Bedside
* routine bloods, blood culture, inflammatory markers, liver function test, troponin, ABG
* finger stick blood glucose
* urine dip
* oxygen sats, BP, ECG
* check polypharmacy
* Ix
* CXR
* CT head - for suspected stroke
* Special
* lumbar punture
43
What are the differentials for delirium?
Common
* dementia
* stroke/TIA
* MI
* pain
Uncommon
* head injury
* adrenal crisis
* thyrotoxicosis
44
What mental test will you perform to assess delirium?
* Confusion Assessment Method (CAM)
* 4AT
45
How would you Mx delirium?
* initial mx
* tx underlying cause - best way to reverse delirium
* ensure effective communication and reorientation
* consider involving family, social care
* if pt is disstressed and at risk to themselves or others
* use verbal and non verbal techniques to de-escalate situation
* haloperidol
* antipsychotic
* physical restrain (last resort)
46
What is the CAM?
To have a positive result the patient must have:
* Acute onset and fluctuating course; and
* Inattention (eg, 20-1 test with reduced capacity to shift attention or keep attention focused); and either
* Disorganised thinking (disorganised or incoherent speech) or
* Changed level of consciousness (usually the patient is lethargic or is in a state of stupor).
47
What is delirium associated with?
* increase mortality
* prolonged hospital admission
* higher complication rates
* institutionalisation
* high risk of developing dementia
48
What are the types of delirium?
* Hyperactive (agitated & confuse)
* Hypoactive (withdrawn and drowsy)
* Mixed
49
What does the 4AT briefly comprise of?
* Alertness
* Abbreviated Mental Test 4 (AMT4)
* age, dob, name of hospital, current year
* Attention
* list months of year backwards
* Acute change or fluctuating course
50
What are examples of potentially treatable dementia?
* Substance misuse
* Hypothyroidism
* Space-occupying intracranial lesions
* Normal pressure hydrocephalus
* Syphilis
* Vitamin B12 deficiency
* Folate deficiency
* Pellagra
Older Persons Medicine
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