Elderly Confusion

Question 1

what is confusion?

Answer 1

the act of confusing or the state of being confused

Question 2

what are the 6 neurocognitive domains and subdomains in DSM5?

Answer 2

Complex attention
perceptual motor function
language function
executive function
learning/memory
social cognition

Question 3

according to DSM 5 what is complex attention

Answer 3

sustained attention
divide attention
selective attention
processing speed

Question 4

according to DSM 5 what is perceptual motor function

Answer 4

visual perception
visuoconstructional reasoning
perceptual motor coordination

Question 5

according to DSM 5 what is language function

Answer 5

object naming
word finding
fluency
grammar and syntax
receptive language

Question 6

according to DSM 5 what is executive function

Answer 6

planning
decision making
working memory
responding to feedback 
inhibition
flexibility

Question 7

according to DSM 5 what is learning/memory

Answer 7

free recall
cued recall
recognition memory
semantic and autobiographical long-term memory
implicit learning

Question 8

according to DSM 5 what is social cognition

Answer 8

recognition of emotion
theory of mind
insight

Question 9

why is assessing cognition important?

Answer 9

may be relevant to current medical problems
associated with increased risk of death/increased LOS/discharge to care home
may need to alter communication/information given/involvement of family members
help you decide regarding capacity
may alter appropriateness of tests/investigations/certain treatments
may be able to improve it

Question 10

what key things must you identify when diagnosing cognitive impairment?

Answer 10

onset - when and how rapid
course - fluctuating, progressive decline
associated features - other illness, functional loss

Question 11

key features of delirium

Answer 11

disturbed consciousness - hypo/hyperactive/mixed
change in cognition - memory/perceptual/language/illusions/hallucinations
acute onset and fluctuant

Question 12

other common features of delirium

Answer 12

disturbance of sleep wake cycle
disturbed psychomotor behaviour
emotional disturbance

Question 13

who gets delirium?

Answer 13

extremes of age
frailty - cognitive frailty, dementia, Parkinson’s
massive insult if young and fit

Question 14

causes of delirium

Answer 14

infection
dehydration
biochemical disturbance - high and low Na,K, high Ca
pain
drugs - indirect - ACEI, NSAIDS resulting in AKI
constipation/urinary retention
hypoxia
alcohol/drug withdrawal
sleep disturbance
brain injury
changes in environment - carers, respite
multiple triggers

Question 15

what is the commonest complication of hospitalisation?

Answer 15

delirium

Question 16

what are the complications of delirium?

Answer 16

increased risk of death
longer stay
increased rates of institutionalisation
persistent functional decline

Question 17

briefly describe the 4AT tool

Answer 17

Alterness
AMT4 = age, DOB, place, current year
Attention = months backwards
Acute change or fluctuating cource

Question 18

briefly describe the T in TIME bundle

Answer 18

NEWS
BM
Medication Hx - any changes
Pain review - Abbey Pain Scale
Urinary retention
Constipation

Question 19

briefly describe the I in TIME bundle

Answer 19

assess hydration and start fluid balance chart
bloods - FBC, U+E, Ca, LFTs, CRP, Mg, Glucose
look for symptoms/signs of infection
ECG

Question 20

briefly describe the M in TIME bundle

Answer 20

initiate treatment of all underlying causes

Question 21

briefly describe the E in TIME bundle

Answer 21

engage with patient, family and carers
explain diagnosis of delirium to patient, family and carers
document diagnosis of delirium

Question 22

non-pharmacological measures in the treatment of delirium

Answer 22

reorientate and reassure agitated patients - families, reintroduce, explain
encourage early mobility and self-care
correction of sensory impairment
normalise sleep- wake cycle
ensure continuity of care - avoid ward and room transfers
avoid urinary catheters and venflons

Question 23

what drugs are bad in delirium?

Answer 23

anticholinergics

sedatives

Question 24

if a delirious patient becomes a danger to themselves or others what medication may you give them?

Answer 24

12.5mg quetiapine

Question 25

define dementia

Answer 25

an acquired decline in memory and other cognitive functions in an alert person sufficiently severe to cause functional impairment and present for more than 6 months

Question 26

types of dementia

Answer 26

``` Alzheimer's Vascular Mixed Dementia with Lewy bodies fronto-temporal ```

Question 27

describe Alzheimer's dementia

Answer 27

slow, insidious onset loss of recent memory first progressive functional decline

Question 28

risk factors for Alzheimer's

Answer 28

age vascular risk factors genetics

Question 29

describe vascular dementia

Answer 29

classically step-wise deterioration executive dysfunction may predominate rather than memory impairment associated with gait problems

Question 30

what vascular risk factors are associated with vascular dementia?

Answer 30

T2DM AF IHD PVD

Question 31

describe dementia with lewy bodies

Answer 31

may have parkinsonism often very fluctuant hallucinations common - psychotic falls common

Question 32

if a person has recurrent delirium what diagnosis may you consider?

Answer 32

dementia with lewy bodies

Question 33

describe fronto-temporal dementia

Answer 33

onset often young early symptoms - behavioural change (aggression), language difficulties (aphasia, dysphasia), memory early on often not affected lack of insight

Question 34

what are some of the problems with tests for diagnosing dementia?

Answer 34

culturally/generationally/intellectually specific can be falsely reassuring - screening and monitoring only patient's don't care about score they want to function independently

Question 35

non-pharmacological treatment of dementia

Answer 35

``` support for person and carers cognitive stimulation exercise environmental design - pictures avoiding changes in environment/social support advanced care planning ```

Question 36

pharmacological treatment of dementia

Answer 36

cholinesterase inhibitors | antipsychotics

Question 37

what cholinesterase inhibitor is licensed in mixed dementia?

Answer 37

galantamine

Question 38

what cholinesterase inhibitor is licensed in lewy body dementia?

Answer 38

rivastigmine

Question 39

what are reversible causes of dementia?

Answer 39

``` hypo/hyper thyroidism intracerebral bleeds/tumours B12 deficiency Hypercalcaemia normal pressure hydrocephalus depression ```