integrated Flashcards
(31 cards)
what is delirium
an acute confusional state, characterised by transient global organic disorder of CNS functioning leading to impaired consciousness and attention, reduced cognitive function. Hypo- hyper- or mixed.
which is the most common type of delirium?
hypoactive but it is underdiagnosed
how does hypoactive delirium present ?
lethargy, reduced motor activity, apathy and sleepiness, can resemble depression
how does hyperactive delirium present ?
agitation, irritability, restlessness, aggression, hallucinations and delusions are prominent, can be confused with psychosis
causes of delirium
usually multifactorial HE IS NOT MAAD
Hypoxia - resp failure, MI, PE, CCF
Endocrine - hypo/hyper - glycaemia/thyroid, CUshings
Infection - UTI, meningitis, LRTI, encephalitis
Sensory - visual/hearing impairment, Stroke
Nutritional - low B1/B12/nicotinic acid
Other - environmental change, sleep deprivation
Theatre - post-op pain, opioids, complications
Metabolic - hyponatraemia, hepatic/renal impairment, electrolyte imbalance
Abdo - constipation + faecal impaction, malnutrition, urinary retention
Alcohol - introxication/DTs
Drugs - Benzos, opioids, anticholinergics, anti-parkinsons, steroids
risk factors for delirium
age 65+, multiple comorbidities, dementia, physical frailty, renal impairment, sensory impairment, previous episodes, recent surgery, severe illness (e.g. CCF)
clinical features of delirium
acute onset and fluctuating course (often worse at night)
Disordered thinking
Emotional - euphoric, fearful, aggressive, depressed
Language impaired - rambling, repetitive, disruptive
Inattention
Reversal of sleep-wake pattern
Illusions, delusions, hallucinations
Unaware - disoriented to time/place/person
Memory deficit
How does delirium differ to dementia?
del - acute/subacute onset; dem = chronic
del = fluctuating course; dem = stable/slowly progressive
del = duration hours to weeks; dem = months-yrs
del = consciousness reduced; dem = not
del = attention severely reduced; dem = same/reduced
del = arousal can be up/down; dem = stable
del = reversed sleep wake cycle; dem = normal
del = fleeting delusions, hallucinations common, abnormal psychomotor acitivity; dem = complex delusions, hallucinations less common, usually normal psychomotor
how would you investigate ?delirium
baseline before referring to memory clinic
FBC, CRP, blood culture, urinalysis + culture (infection)
U+Es, calcium (electrolyte disturbance)
LFTs, B12/folate/ferritin (alcohol/liver disease/malnutrition)
TFT (up/down), glucose (up/down)
ECG + CXR (± CThead/LP/EEG/ABG if clinically indicated)
AMT+CAM or MMSE
Ddx delirium
dementia, mood disorder, late onset schizophrenia, dissociative disorder, hypo/hyper-thyroid
Mx delirium
rx underlying cause, reassure and reorientate, optimise environment (visual/hearing aids, well lit side room no changing, continuity of care, family/friends visit), challenging behaviour (de-escalation technique e.g. redirection, monitor oral intake and continence, if severe and a risk to self/others consider PO haloperidol)
what is dementia
syndrome of generalised decline of memory, intellect and personality without impairment of consciousness, that leads to functional impairment
most common cause of dementia
Alzheimers disease
macroscopic and microscopic changes seen in Alzheimers disease
Macro - cortical atrophy esp around hippocampus, widened sulci, enlarged ventricles
micro - neurofibrillary tangles (intracellularly) and b-amyloid plaques (extracellularly)
pathophysiology of Alzheimers disease
degeneration of cholinergic neurones in the nucleus basalts of meynert causing ACh deficiency
pathophysiology of dementia with lewy bodies
abnormal deposition of proteins in neurones of brainstem/SNi/neocortex. deposition inside brainstem causes Parkinson sx due to reduced dopamine, outside brainstem causes deficiency of acetylcholine.
pathophysiology of frontotemporal dementia
frontal and temporal lobe atrophy - inc Picks disease with protein tangle (picks bodies) seen on histology
reversible causes of dementia
Drugs - barbiturates Eyes and ears - visual/hearing impairment Metabolic - Cushings and hypothyroid Emotional - depression = pseudo dementia NPH Tumours/trauma Infection e.g. encephalitis Alcoholism/atherosclerosis
how does Parkinsons disease with dementia differ in presentation to dementia with levy bodies
PDD - Parkinsons precedes dementia usually by 4-5yrs, whereas DLB - dementia and Parkinsonism within 1yr of each other, visual hallucinations, poor response to cocareldopa
irreversible causes of dementia
AD, vascular dementia, DLB, FTD, Parkinson’s disease with dementia, Huntingtons disease, cJD, Korsakoff syndrome, TBI
risk factors for alzheimers
increase age, family hx, genetics (presenilin 1, 2 and APP associated with early onset, ApoE4 associated with late onset, ApoE2 protective), trisomy 21 (risk early onset), low IQ, cerebrovascular disease (risk vascular dementia which can coexist), vascular risk factors.
How does Alzheimers present?
early - trouble finding words, forgetting names of people/places, memory lapse
progression - apraxia, confusion, language problems, difficulty with executive thinking, inability to retain new information starts spreading to long term memory
late - disorientation to time and place, wandering, apathy, incontinence, eating problems, depression, agitation
at what age is Alzheimers early onset
<65 - usually familial
How does vascular dementia usually present?
60s/70s with stepwise progression, memory loss, emotional and personality changes, confusion is common, cardiovascular risk factors/disease, can have neurological sx (O/E usually UMN. hyperreflexia, extensor plantar, unilateral spastic weakness)
