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Flashcards in OP: Dementia + Delerium Deck (66)
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1
Q

What is delirium?

A

Acute, transient and reversible state of confusion ( global disorder of cognition and consciousness). often due to other cause (infection, drugs, dehydration).

Onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.

2
Q

What 2 states of delirium can you get?

A

HYPOactive

HYPERactive

3
Q

what are clinical features of hypoactive delirium?

A

(often confused with depression)

Lethargy
withdrawn
Inattention
Slowness with everyday tasks
Excessive sleeping

4
Q

what are clinical features of hyperactive delirium?

A

Agitation
Delusions
Hallucinations
Wandering
Aggression

5
Q

Patients CAN fluctuate between hypoactive and hyperactive delirium - TRUE OR FALSE?

A

TRUE

6
Q

Causes of delirium? CHIMPS PHONED

A

Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness

Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic / renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)

7
Q

Assessing the confused patient:

in medical notes look for relevant past medical history such as…

A

Previous episodes of confusion

head injury

recent admission

stroke

atherosclerosis

8
Q

Assessing the confused patient:

in medical notes look for current medications….

A

review drugs that may cause / contribute to confusion

e.g. opiates
anticholinergics
benzodiazepams
steroids
Antihistamines
antipsychotics
antidepressants
parkinson drugs

9
Q

Assessing the confused patient:

in medical notes look for social Hx….

A

Home situation - carers / live alone
evidence of how coping
excess alcohol
excessive drug use

10
Q

What bloods do you need to request for a confusion screen for your patient? And what looking for?

A

FBC (e.g. infection, anaemia, malignancy)

U&Es (e.g. hyponatraemia, hypernatraemia)

LFTs (e.g. liver failure with secondary encephalopathy)

Coagulation/INR (e.g. intracranial bleeding)

TFTs (e.g. hypothyroidism)

Calcium (e.g. hypercalcaemia)

B12 + folate/haematinics (e.g. B12/folate deficiency)

Glucose (e.g.
hypoglycaemia/hyperglycaemia)

Blood cultures (e.g. sepsis)

11
Q

What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?

A

most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.

Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture

12
Q

What questions does the Abbreviated Mental Test Score (AMTS) ask?

A

Ask the patient:

  1. “What is your age?”
  2. “What is the time to the nearest hour?”
  3. Give the patient an address, and ask them to repeat it at the end of the test (e.g. “42 West Street”)
  4. “What is the year?”
  5. “What is the name of this place?” or “What is your house number?”
  6. Can the patient recognise two persons (e.g. doctor, nurse)?
  7. “What is your date of birth?” (day and month sufficient)
  8. “In what year did World War 1 begin?”
  9. “Name the present monarch/prime minister/president”
  10. “Count backwards from 20 down to 1”

Each questions answered CORRECTLY. gets 1 point.
SCORE OF 6 or less suggests DEMENTIA ? DELIRIUM - further tests to confirm which

13
Q

What would you look for in clinical examination of someone you are assessing for delirium?

A

Vital signs (e.g. fever in infection, low SpO2 in pneumonia)

Level of consciousness (e.g. GCS/AVPU)

Evidence of head trauma

Sources of infection (e.g. suprapubic tenderness in urinary tract infection)

Asterixis (e.g. uraemia/encephalopathy)

14
Q

There is a patient with suspected delirium- you are asked to do a confusion screen.

What 3 categories of investigation does this involve?

A

Bloods
Urinanalysis
Imaging

15
Q

What bloods do you need to request for a confusion screen for your patient? And what looking for?

A

FBC (e.g. infection, anaemia, malignancy)

U&Es (e.g. hyponatraemia, hypernatraemia)

LFTs (e.g. liver failure with secondary encephalopathy)

Coagulation/INR (e.g. intracranial bleeding)

TFTs (e.g. hypothyroidism)

Calcium (e.g. hypercalcaemia)

B12 + folate/haematinics (e.g. B12/folate deficiency)

Glucose (e.g.
hypoglycaemia/hyperglycaemia)

Blood cultures (e.g. sepsis)

16
Q

What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?

A

most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.

Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture

17
Q

What imaging do you need to do for a confusion screen for your patient? What looking for?

A

CT head- intracranial pathology (bleeding, ischaemic stroke, abscess)

Chest X-ray - pneumonia, pulmonary oedema

18
Q

What is definitive management of delirium?

A

treat underlying cause

19
Q

Supportive management of delirium?

A
  • Pt has access to aids e.g. hearing aids/ glasses/ walking stick
  • encourage independent activities e.g. washing / eating/ toileting
20
Q

Environmental management of delirium?

A
  • Access to clock and other orientation reminders

-familiar obects - photos/ wear own clothes

  • involve family / regular carers
  • ensure lighting and temperature optimal
21
Q

Why must be very careful in treating an elderly patient for delirium when they have a background of Parkinsons / Lewy Body dementia?

A

Haloperidol 0.5 mg is the 1st-line sedative (oral preferred or IM if refused to take + immediate threat to others)

Parkinson’s disease- antipsychotics can worsen symptoms
1. Reduce Parkinson meds
2. if urgent treatment - use atypical antipsychotics e..g clozapine

22
Q

What score can we use in a clinical setting to evaluate for frailty?

A

Rockwood clinical frailty score >65yrs

23
Q

Some steps to prevent delirium?

A

avoid drugs that cause: opiates / benzodiazepines

asses factors that cause: pain control / drugs

Identify those at risk and monitor

use supportive and environmental management approaches for all patients

24
Q

Define capacity

A

The ability to 1) understand, 2) retain, 3) weigh up information and 4) communicate a decision

25
Q

When assessing capacity, what assumption should you start with?

A

Always start with the assumption that the patient DOES have capacity.

26
Q

What steps are taken in assessing capacity?

A
  1. Maximise capacity - i.e. start from the presumption that patient has capacity to make decision. Offer audio/written information. Have family/friends present to help communicate. Discuss options in a way that they remember

Still unsure if pt has capacity? Move to step 2.

  1. Assess capacity - can they understand? Retain?
    Weigh up info? Communicate decision?

If not - need advanced decisions as pt may lack capacity.

  1. Next - Is there an advance decision to refuse treatment (always present in England).? Has someone else been given legal authority to make decision?
    If yes, that makes decision. If not, you make decision.
  2. Reach agreement with team about treatment and care.
27
Q

Characteristic pathological feature of Lewi-Body dementia?

A

alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.

28
Q

Features of Lewy-Body dementia?

A

Progressive cognitive impairment
Parkinsonism
Visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)

29
Q

Difference in features of Alzehimers and Lewy-Body

A

Lewy body- progressive cognitive impairment
Alzheimers- early impairment in attention/memory and executive function rather than just memory loss and cognition may be fluctuating

30
Q

Diagnosis of Lewy body dementia?

A

Usually clinical
Increasing use of single-photon emission computed tomography (SPECT)
The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%

31
Q

Management of Lewy body dementia?

A

both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s

32
Q

Drug to avoid in Lewy body dementia and why?

A

neuroleptics should be avoided in Lewy body dementia–>patients are extremely sensitive and may develop irreversible parkinsonism.

33
Q

Pathophysiology of Alzheimers?

A

cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein

34
Q

Name a NMDA receptor antagonist?

A

Memantine

35
Q

Memantine indications?

A

Alzheimers
Lewy body dementia

36
Q

What features make delirium a more likely diagnosis than dementia? (Pass Med)

A

Fluctuating symptoms e.g. worse at night, then normal

Impairment of consciousness (dementia does not see this until very late on)

Abnormal perception (e.g. illusions and hallucinations)

Agitation, fear

Delusions

37
Q

If of the main factors of delirium is impairment of consciousness, how would you evaluate for this in your in your patient?

A

Reduced score on the Glasgow coma scale e.g. 12/ 15

often accompanied with psychotic symptoms

38
Q

Why must be very careful in treating an elderly patient for delirium when they have a background of Parkinsons / Lewy Body dementia?

A

Haloperidol 0.5 mg is the 1st-line sedative

Parkinson’s disease- antipsychotics can worsen symptoms
1. Reduce Parkinson meds
2. if urgent treatment - use atypical antipsychotics e..g clozapine

39
Q

What given for patient with delirium when Haloperidol contraindicated? Why would it be?

A

Low-dose lorazepam if haloperidol is contraindicated (atpical)

for people with Parkinson’s disease, Lewy-body dementia, or prolonged QT interval

40
Q

What is delirium?

A

Acute confusional state, sudden onset and fluctuating state

41
Q

How long does delirium develop over?

A

1-2 days

42
Q

How can you recognise delirium?

A

Change in consciousness either hyper or hypo alert and inattention

43
Q

What is delirium an indication of?

A

Frailty

44
Q

What is delirium associated with?

A

Increased mortality
prolonged hospital admission,
higher complication rates
institutionalisation and increased risk of developing dementia

45
Q

What is the resolution of delirium like?

A

It takes a while to resolve and can take up to 3 months to get back to normal level of functioning.

Some people may never return to their baseline

46
Q

What cognitive assessment tool could you use for a pt with suspected dementia ?

A

NICE -lots
e.g 6-point `Cognitive impairment test (6-CIT)

  • temporal orientation
  • address recall
  • count back from 20
  • months of the year in reverse

Score 0-7 out of 28 = normal
8 or more out of 28 = significant

Oxford clinical med book says AMTS and Mental state examination

47
Q

What are some reversible causes of dementia you might find on investigation (bloods)

A

high TSH - hypothyroidism
Low B12
Low folate
low thiamine (alcohol)
low Ca

48
Q

What bloods would you order for pt with dementia ?

A

FBC
ESR / CRP
U&E
Ca
HbA1c
LFT
TFT
serum B12/folate

49
Q

What bedside investigations might you do for dementia patient?

A

urine microscopy and culture (if indicated)

ECG

50
Q

What imaging might you order for dementia pt?

A

MRI / CT - rule out subdural haematoma / normal pressure hydrocephalus

CXR - infection

EEG - suspect delirium, front temporal dementia, CJD, seizure

51
Q

Define dementia

A

Dementia is irreversible, progressive decline and impairment of more than one aspect of higher brain function (concentration, memory, language, personality, emotion).

This occurs without impairment of consciousness.

52
Q

What is the most common type of dementia in UK

A

Alzheimer’s dementia

53
Q

What histological finding is seen in Alzheimer’s?

A

amyloid plaques (clumps of beta-amyloid) and neurofibrillary tangles ( tau protein).

54
Q

What are the clincial features of Alzeimer’s?

A

Progressive global cognitive loss (can affect all areas of brain)

most common is memory loss. Executive function loss (planning / reasoning)
speech
visuo-spatial skill: orientation.

55
Q

RF for Alzheimers

A

1st degree relative
Downs syndrome
loneliness (living alone)
low physical activity
smoking
Vascular (high BP, DM, dyslipidaemia, AF)

56
Q

Management of Alzheimers?

A

Acetylcholinesterase Inhibitors - Rivastigmine

Memantine - NMDA antagonist for severe disease / AChE not tolerated

57
Q

How common is vascular dementia?

A

2nd most common type

58
Q

What are some RF for vascular dementia

A

9x risk if had a stroke
hypertension
smoking
diabetes
hyperlipidaemia
obesity
hypercholesterolaemia

59
Q

What happens in vascular dementia and how does it progress?

A

multiple small cerebrovascular infarcts

stepwise progression - stable period and then acute deterioration

60
Q

What are the clinical features of vascular dementia?

A

cognitive impairment following event

mood disorders - psychosis, delusions, hallucinations and paranoia

Seizures
Memory disturbance
Gait/speech/emotional disturbance
Attention difficulty
Visual / motor symptoms

61
Q

What do you find histologically in Lewy body dementia?

A

Spherical Lewy body proteins (alpha-synuclein) are deposited in the brain.

Lewy body proteins deposited mainly in substantia nigra in Parkinson’s disease.

62
Q

What are the clinical features of Lewy body dementia

A

Fluctuating cognitive impairment

detailed visual hallucinations

later Parkinsonism develops

problems with complex tasks and sleep disorders common

63
Q

What happens to brain in fronto-temporal dementia?

A

Frontal and temporal atrophy with loss of spindle neurons

64
Q

What are the clinical feature of fronto-temporal dementia?

A

executive impairment
behavioural changes- disinhibition
emotional apathy
inability to recognise faces/objects
speech takes effort / not fluent

65
Q

What are some differencials for dementia?

A

HIV related dementia
Normal pressure hydrocephalus
Creutzfeldt-Jakob disease
Severe depression

66
Q

What medications can impair cognition and look like dementia

A

Anticholinergics
sedatives - benzodiazepams
opioids
corticosteroids

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