Passmed wrong answers Flashcards
(40 cards)
What is acute confusional state and what are the risk factors?
Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital.
It is characterised using the Confusion Assessment Method as an acute onset of a change in mental state from the patient’s baseline with inattention, in addition to either disorganised thinking or altered consciousness. Sleep-wake cycle is often reversed.
Predisposing factors include:
- age > 65 years
- background of dementia
- significant injury e.g. hip fracture
- frailty or multimorbidity
- polypharmacy
What can precipitate delirium?
The precipitating events are often multifactorial and may include:
- infection: particularly urinary tract infections
- metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
- change of environment
- any significant cardiovascular, respiratory, neurological or endocrine condition
- severe pain
- alcohol withdrawal
- constipation
- medications eg opioids
- Hypoxia
What are the features of delirium?
Features - a wide variety of presentations
- memory disturbances (loss of short term > long term)
- may be very agitated or withdrawn
- disorientation
- mood change
- visual hallucinations
- disturbed sleep cycle
- poor attention
How is delirium managed?
- treatment of the underlying cause
- modification of the environment
- haloperidol or olanzapine as the first-line sedative
- management can be challenging in patients with Parkinson’s disease, as antipsychotics can often worsen Parkinsonian symptoms
careful reduction of the Parkinson medication may be helpful - if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred
What is the distinctive feature of vascular dementia?
Vascular dementia can present in a stepwise manner, with sudden progression of symptoms corresponding to new vascular events between stable periods. The past medical history of vascular risk factors are also supportive.
What is vascular dementia?
Vascular dementia (VD) is the second most common form of dementia after Alzheimer disease. It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease. Vascular dementia has been increasingly recognised as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment (VCI). Early detection and an accurate diagnosis are important in the prevention of vascular dementia.
What are the 3 main subtypes of vascular dementia?
- Stroke-related VD – multi-infarct or single-infarct dementia
- Subcortical VD – caused by small vessel disease
- Mixed dementia – the presence of both VD and Alzheimer’s disease
What are the risk factors for vascular dementia?
Risk factors
- History of stroke or transient ischaemic attack (TIA)
- Atrial fibrillation
- Hypertension
- Diabetes mellitus
- Hyperlipidaemia
- Smoking
- Obesity
- Coronary heart disease
- A family history of stroke or cardiovascular
Rarely, VD can be inherited as in the case of CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy).
What are the features of vascular dementia?
Patients with VD typically presents with
Several months or several years of a history of a sudden or stepwise deterioration of cognitive function.
Symptoms and the speed of progression vary but may include:
- Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
- The difficulty with attention and concentration
- Seizures
- Memory disturbance
- Gait disturbance
- Speech disturbance
- Emotional disturbance
How is vascular dementia diagnosed?
Diagnosis is made based on:
1. A comprehensive history and physical examination
2, Formal screen for cognitive impairment
3. Medical review to exclude medication cause of cognitive decline
4. MRI scan – may show infarcts and extensive white matter changes
NINDS-AIREN criteria for probable vascular dementia:
1. Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event
- established using clinical examination and neuropsychological testing
2. Cerebrovascular disease
- defined by neurological signs and/or brain imaging
3. A relationship between the above two disorders inferred by:
- the onset of dementia within three months following a recognised stroke
- an abrupt deterioration in cognitive functions
- fluctuating, stepwise progression of cognitive deficits
How is vascular dementia managed?
- General management
- Treatment is mainly symptomatic with the aim to address individual problems and provide support to the patient and carers
- Important to detect and address cardiovascular risk factors – for slowing down the progression - Non-pharmacological management
- Tailored to the individual
- Include: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy
- Managing challenging behaviours e.g. address pain, avoid overcrowding, clear communication - Pharmacological management
- There is no specific pharmacological treatment approved for cognitive symptoms
- Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.
- There is no evidence that aspirin is effective in treating patients with a diagnosis of vascular dementia.
Which medications are associated with an increased mortality in dementia patients?
Antipsychotics are associated with a significant increase in mortality in dementia patients and should only be used with caution for patients at risk of harming themselves or others, or when the agitation, hallucinations, or delusions are causing them severe distress as in this case.
How is Alzheimer’s disease managed?
- Non-pharmacological management
- a range of activities to promote wellbeing that are tailored to the person’s preference
- group cognitive stimulation therapy for patients with mild and moderate dementia
- other options to consider include group reminiscence therapy and cognitive rehabilitation - Pharmacological management
- the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
- memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer’s, NICE recommend it is used in the following situation reserved for patients with:
*moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
*as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
*monotherapy in severe Alzheimer’s - Managing non-cognitive symptoms
- NICE does not recommend antidepressants for mild to moderate depression in patients with dementia
- antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress
When is donepezil use for alzheimer’s disease contraindicated?
contraindicated in patients with bradycardia
adverse effects include insomnia
What are the 3 types of delirium?
There are three subtypes of delirium -
1. hyperactive,
2. hypoactive, and
3. mixed.
People are well acquainted with the hyperactive form, but the hypoactive subtype is very common as well. Symptoms include being withdrawn, lethargic, and slow to respond.
What are the types of frontotemporal dementia?
Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer’s and Lewy body dementia.
There are three recognised types of FTLD
1. Frontotemporal dementia (Pick’s disease)
2. Progressive non fluent aphasia (chronic progressive aphasia, CPA)
3. Semantic dementia
What are the common features of the 3 types of frontotemporal lobar dementia?
- Onset before 65
- Insidious onset
- Relatively preserved memory and visuospatial skills
- Personality change and social conduct problems
What are the features of Pick’s disease (frontotemporal dementia)? What changes in the brain are seen?
- May also be called behavioural-variant frontotemporal dementia*
This is the most common type of frontotemporal lobar dementia and is characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, loss of sympathy/empathy, perseveration/ compulsive behaviours, executive dysfunction with relative sparing of memory and visuospatial functions.
Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease.
Macroscopic changes seen in Pick’s disease include:-
Atrophy of the frontal and temporal lobes
Microscopic changes include:-
- Pick bodies - spherical aggregations of tau protein (silver-staining)
- Gliosis
- Neurofibrillary tangles
- Senile plaques
Is frontotemporal dementia treated similarly to Alzheimer’s disease?
No
NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia
What is the main feature of chronic progressive aphasia (CPA)?
This is a subtype of frontotemporal dementia so the common features are seen.
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
What is the main feature of semantic dementia?
This is a subtype of frontotemporal dementia so the common features are seen.
Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.
What risk does lorazepam increase in geriatric patients?
Risk of falls
What is Lewy body dementia and what is the characteristic pathology?
Lewy body dementia is an increasingly recognised cause of dementia, accounting for up to 20% of cases. The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
The relationship between Parkinson’s disease and Lewy body dementia is complicated, particularly as dementia is often seen in Parkinson’s disease. Also, up to 40% of patients with Alzheimer’s have Lewy bodies.
What are the features of Lewy body dementia?
- progressive cognitive impairment
- typically occurs before parkinsonism, but usually both features occur within a year of each other. This is in contrast to Parkinson’s disease, where the motor symptoms typically present at least one year before cognitive symptoms
- cognition may be fluctuating, in contrast to other forms of dementia
- in contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss - parkinsonism
- visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
- REM-sleep behaviour
