integrated

Question 1

what is delirium

Answer 1

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.

Question 2

which is the most common type of delirium?

Answer 2

hypoactive but it is underdiagnosed

Question 3

how does hypoactive delirium present ?

Answer 3

lethargy, reduced motor activity, apathy and sleepiness, can resemble depression

Question 4

how does hyperactive delirium present ?

Answer 4

agitation, irritability, restlessness, aggression, hallucinations and delusions are prominent, can be confused with psychosis

Question 5

causes of delirium

Answer 5

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

Question 6

risk factors for delirium

Answer 6

age 65+, multiple comorbidities, dementia, physical frailty, renal impairment, sensory impairment, previous episodes, recent surgery, severe illness (e.g. CCF)

Question 7

clinical features of delirium

Answer 7

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

Question 8

How does delirium differ to dementia?

Answer 8

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

Question 9

how would you investigate ?delirium

Answer 9

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

Question 10

Ddx delirium

Answer 10

dementia, mood disorder, late onset schizophrenia, dissociative disorder, hypo/hyper-thyroid

Question 11

Mx delirium

Answer 11

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)

Question 12

what is dementia

Answer 12

syndrome of generalised decline of memory, intellect and personality without impairment of consciousness, that leads to functional impairment

Question 13

most common cause of dementia

Answer 13

Alzheimers disease

Question 14

macroscopic and microscopic changes seen in Alzheimers disease

Answer 14

Macro - cortical atrophy esp around hippocampus, widened sulci, enlarged ventricles
micro - neurofibrillary tangles (intracellularly) and b-amyloid plaques (extracellularly)

Question 15

pathophysiology of Alzheimers disease

Answer 15

degeneration of cholinergic neurones in the nucleus basalts of meynert causing ACh deficiency

Question 16

pathophysiology of dementia with lewy bodies

Answer 16

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.

Question 17

pathophysiology of frontotemporal dementia

Answer 17

frontal and temporal lobe atrophy - inc Picks disease with protein tangle (picks bodies) seen on histology

Question 18

reversible causes of dementia

Answer 18

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

Question 19

how does Parkinsons disease with dementia differ in presentation to dementia with levy bodies

Answer 19

PDD - Parkinsons precedes dementia usually by 4-5yrs, whereas DLB - dementia and Parkinsonism within 1yr of each other, visual hallucinations, poor response to cocareldopa

Question 20

irreversible causes of dementia

Answer 20

AD, vascular dementia, DLB, FTD, Parkinson’s disease with dementia, Huntingtons disease, cJD, Korsakoff syndrome, TBI

Question 21

risk factors for alzheimers

Answer 21

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.

Question 22

How does Alzheimers present?

Answer 22

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

Question 23

at what age is Alzheimers early onset

Answer 23

<65 - usually familial

Question 24

How does vascular dementia usually present?

Answer 24

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)

Question 25

How does Dementia with Lewy bodies present?

Answer 25

day to day fluctuations in cognition
recurrent visual hallucinations
motor sx of parkinsonism, recurrent falls / syncope / depression; very sensitive to neuroleptic

Question 26

How does frontotemporal dementia present?

Answer 26

onset 50-60y/o, family hx in 50%. early changes - lack of insight with insidious personality changes (disinhibition, apathy, restlessness), decline in social behaviour, repetitive behaviour, language problems. Memory loss comes later.

Question 27

How does Huntington’s disease present?

Answer 27

autosomal dominant so positive family hx

choreiform movements of hands, shoulders, face; gait abnormality; dementia and personality changes

Question 28

Ix ?dementia

Answer 28

refer to memory clinic
confusion bloods - FBC, U+Es, LFTs, TFTs, CRP, ca, glucose, vit B12/folate/ferritin
guided by hx - urine dipstick and culture, CXR, CT/MRI head (<60/acute rapid decline/focal neuro), ECG, LP, genetic testing

Question 29

Mx dementia

Answer 29

inform DVLA. discuss ACP - LPA, advanced statements, preferred place of care. Themes of care:

• cognitive enhancement - mild-mod AD AChesterase inhibitors (donepezil, rivastigmine, galantamine), severe AD NMDA receptor antagonist (memantine)
• rx agitation - reassure, de-escalation, continuity of care, social support, ?animal/music/aroma therapy; still challenging ?short course antipsychotic
• rx low mood and insomnia - therapies as above, community services e.g. befriending service, social support groups, antidepressants only if severe depression
• functional support - OT assessment home safety, meals on wheels, day centres, respite care, care home, community dementia team, home nursing and personal care, increased assistance with day to day activities
• social support - community services such as befriending services, day centres, social worker, support groups
• support for carers - information and education, carers allowance, support networks

Question 30

what drug treatment should be AVOIDED in DLB

Answer 30

neuroleptics - antipsychotics esp haloperidol can cause irreversible Parkinsonism. Use lorazepam instead for any severe agitation/problem behaviour

Question 31

what medication is used to treat severe agitation in delirium in a patient with parkinsons

Answer 31

lorazepam - don’t use anti-psychotics like haloperidol as they often have strong anti-dopaminergic action, and as such in a patient with Parkinson’s, they will make their condition significantly worse