Elderly Confusion

Question 1

What are the types of delirium?

Answer 1

Hypoactive - Lethargic, stupor
Hyperactive - Combative, agitated & restless

Mixed

Question 2

How does delirium typically present?

Answer 2

with changes in cognition e.g. memory. perception, language & hallucinations

It has an acute onset and fluctuates, typically being worse at night

Can also affect sleep cycle & emotions

Question 3

What causes delirium?

Answer 3

It’s generally triggered by multiple factors such as:

• Infection
• Dehydration or biochemical imbalance
• Pain
• Sleep disturbance
• Drugs (or drug withdrawel)
• Hypoxia
• Brain injury
• Environment or social changes

Question 4

How do we diagnose Delirium?

Answer 4

It’s a clinical diagnosis and we can use the 4AT score to help us. 4 or more points = possible delirium +/- cognitive impairment

Question 5

What’s included in a 4AT score?

Answer 5

Alertness
AMT4 (Age, DOB, location & yr)
Attention (tell me months of year backwards starting at december)
Acute change or fluctuation

Question 6

How do we assess a patient with delirium?

Answer 6

Full H & E including neuro

Time bundle - A systematic way of identifying triggers and initiating treatment

Question 7

What non-pharmacological ways can we treat delirium?

Answer 7

First make sure you explain delirium to the patient and carer.

• Reassurance
• Encourage early mobility
• Correct any sensory impairment
• Normalise sleep-wake cycle
• Ensure continuity of environment & carers
• Avoid catheters and venflons

Question 8

When would you use drugs in delirium?

Answer 8

Only if distress can’t be resolved otherwise.
Or if a danger to themselves or others

DONT JUST SEDATE THE POOR FUCKERS

Question 9

What drugs can you use for delirium?

Answer 9

Firstly stop potentially precipitating drugs, mostly anti-cholinergics and sedatives

Start with low dose of 12.5mg quetiapine orally

Question 10

Define dementia?

Answer 10

Acquired decline in cognitive functions in an alert person severe enough to cause functional impairment and present >6months

Functional impairment means forgetting tablets, can’t work phone or difficulty washing/dressing etc (as long as it’s a cognitive cause)

Question 11

What are the big types of dementia?

Answer 11

Alzheimers
Vascular dementia
Lewy body dementia
Frontotemporal dementia

Question 12

How does alzheimers present?

Answer 12

Slow insidious onset with memory going first

Think age, vascular and genetic risk factors

Question 13

How would vascular dementia present?

Answer 13

Step-like deterioration
Starts with executive function and associated with gait problems

Look for vascular risk factors e.g. IHD, DM, AD or PVD

Question 14

How does lewy body dementia present?

Answer 14

Very fluctuant
Often comes with hallucinations and falls
Possible parkinsonism

Question 15

How does frontotemporal dementia present?

Answer 15

Earlier
Behavioral changes
Language problems
Memory (though often unaffected)

Question 16

How do we diagnose dementia?

Answer 16

Again there’s no test for it.

The MMSE & MOCA can help with screening and monitoring but are not diagnostic

Question 17

Most dementia care is non-pharmacological, what does this include?

Answer 17

support and education of the person & carers
Cognitive stimulation
Exercise
Environmental design (to make things as simple and obvious as possible)
Avoid changes in environment and social support
Advanced care planning (including proxy)

Question 18

What drugs are available for dementia?

Answer 18

Cholinesterase inhibitors

Anti-psychotics (avoid if at all possible)

Question 19

What types of dementia do cholinesterase inhibitors treat?

Answer 19

Mostly alzheimers but also:

• Galantamine for mixed dementia
• Rivastigmine for Lewy body

These won’t cure it but can improve the MMSE and delay the need to go to a care home

Question 20

What reversible conditions could cause dementia?

Answer 20

Hypothyroidism
B12 deficiency
Hypercalcaemia
Intracerebral bleeds/tumours
NPH