Selected Notes gerries Flashcards by Anastasia Goeldner-Thompson

Q

What is benign paroxysmal positional vertigo?

A

<ul><li>Sudden episodic attacks of vertigo induced by changes in head position</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Describe the epidemiology of benign paroxysmal positional vertigo

A

<ul><li>Leading cause of vertigo</li><li>Increased incidence in the elderly</li><li>Increased risk in those with gallstones(calcium deposits)</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Describe the aetiology of benign paroxysmal positional vertigo

A

<ul><li>Detachment of otoliths from the utricle of the inner ear</li><li>Detached particles migrate into semicircular canals where they stimulate hair cells and lead to vertigo symptoms</li><li>Acummulation of cholelithiasis in semi circular cells of inner earrr</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Describe the presentation of patient with benign paroxysmal positional vertigo

A

<ul><li>Vertigo triggered by changes in head position (e.g. rolling in bed, looking up)</li><li>Recurrent episodes lasting aroung 30secs-1 minute</li><li>May be associated with nausea </li><li>No auditory symptoms</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How is benign paroxysmal positional vertigo diagnosed?

A

<ul><li>Positive Dix-Hallpike maneouvre</li><li>Lie down with one ear pointed to ground-> check for nystagmus</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Name some differentials for benign paroxysmal positional vertigo

A

<ul><li>Menieres disease</li><li>Vestibular neuritis</li><li>Labyrinthitis</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How is benign paroxysmal positional vertigo managed?

A

<ul><li>Epley manouvere-works in around 80%(aims to detach otoliths out of semicircular canal and back to utricle)</li><li>Usuaully resolves spontaneously after a few weeks/months</li><li>Can teach patients at home exercises: 'vestibular rehab': e.g Brandt-Daroff exercises</li><li>Betahistine not very useful</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Describe the prognosis for benign paroxysmal positional vertigo

A

<ul><li>1/2 will have recurrence of sx 3-5 years after diagnosis</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

What group of patients are more at risk of developing pressure ulcers?

A

<ul><li>Patients who are unable to move parts of their body due to illness, paralysis or advancing age</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Where do pressure ulcers typicallly develop?

A

<ul><li>Over bony prminences like the sacrum or heel</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Name some risk factors for developing pressure ulcers?

A

<ul><li>Malnourishment</li><li>Incontinence-> urinary and faecal</li><li>Lack of mobility</li><li>Pain-> leads to decreased mobility</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

What scoring system is used to grade pressure ulcers?

A

<ul><li>Waterlow score</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

<b>Pressure ulcers grading:</b><br></br>Grade 1: {{c1::non-blanchable erythema of intact skin. Discolourationof skin, warmth, oedema or hardness used as indicators}}<br></br>Grade 2: {{c2::Partial thickness skin loss involving epidermis/dermis or both. Ulcer is superficial and present clinically as an abrasion/blister}}<br></br>Grade 3: {{c3::Full thickness skin loss involving damage to or necrosis of SC tissue that may extend down to but not through underlying fascia}}<br></br>Grade 4: {{c4::Extensive destruction, tissue necrosis ordamage to muscle, bone or supporting structures with/wihtout full thickness skin loss}}

A

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How are pressure ulcers manageed?

A

<ul><li>Moist wound environemnt: hydrocolloid dressings and hydrogels(no soap)</li><li>Wound swabs not routinely done-> systemic abx use decided on clinical basis(surrounding cellulitis etc)</li><li>Consider referral to tissue viability nurses</li><li>Surgical debriedement for selected wounds</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Whata re lower urinary tract sympotms?

A

<ul><li>Group of sx that occur as a result of abnormal storage, voiding or post micturition function of bladder, prostate or urethra</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Describe the aetiology of LUTS

A

<ul><li>Neurological</li><li>Bladder</li><li>Prostate</li><li>Urethral</li><li>Other mass effect</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How can LUTS be classified?

A

<ul><li>Voiding</li><li>Storage</li><li>Post-micturition</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Name somee voiding symptoms LUTS

A

<ul><li>Hesitancy</li><li>Straining</li><li>Terminal dribbling</li><li>Incomplete emptying</li><li>Weak/intermittent urinary stream</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Name some storage sx LUTS

A

<ul><li>Urgency</li><li>Frequency</li><li>Nocturia</li><li>Urinary incontinence</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Name some post-micturition sx LUTS

A

<ul><li>Post-micturition dribbling</li><li>Sensation of incomplete emptying</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Name some differentials for LUTS

A

<ul><li>Bladder outlet obstruction</li><li>Overactive bladder syndorme</li><li>Urethral stricture</li><li>Prostatitis</li><li>Bladder cancer</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

What investigations might be done in a patient presenting with LUTS?

A

<ul><li>Urinalysis: exclude infection and check for haematuria</li><li>DRE: size and consistency of prostate</li><li>PSA test may be considered</li><li>Bladder diary</li><li>Urodynamic studies</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How are LUTS managed?

A

<ul><li>Treat undelrying cause</li><li>Depends on type of LUTS</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

How aare voiding LUTS managed?

A

<ul><li>Conservatrive: pelvic floor/bladder trianing</li><li>BPH-5-alpha reductase inhibitor-finasteride</li><li>Alpha blocker if severe-doxazosin</li></ul>

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

How are voiding and storage LUTS managed?

Alpha blocker-doxazosin
Add anticholinergic-oxybutinin

How are overactive bladder symptoms managed?

Conservative: fluid management
Antimuscarininc if persistent-oxybutinin, tolteridone

How is nocturia managed?

Manage fluid intake at night
Furosemide 40mg in late afternoon
Desmopressin

What are the different types of urinary incontinence?

Stress-> leaking small amounts when laughing/coughing
Urge/overactive-> detrusor overactivityy
Mixed: urge/stress
Overflow-> bladder outlet obstruction
Functional

What causes overflow incontinence

Bladder outlet obstruction(e.g. prostate enlargement)

Name some reversible causes of urinary incontinence

DIAPPERS

Delirium
Infection
Atrophic vaginitis/urethritis
Pharmaceutical(medications)
Psychiatric disorders
Endocrine disorders(diabetes)
Restricted mobility
Stool impaction

What investigations migh tbe done to look for causes of urinary incontinence?

Physical exam: organ prolapse ad ability to contract pelvic floor muscles
Bladder diary: number and types of incontinence
Urinalysis: rule out infection
Cytometry: measurees bladder presure whilse voiding(not recommended where clear diagnosis)
Cystogram: Contrast in bladder and imaging(fistula)

What is stress incontinence?

Leaking of urine when abdominal pressure is high-> increases pressure on bladder

Name some risk factors for stress incontinence

Childbirth(especially vaginal)-> injury to pelvic floor muscles and connective tissue
Hysterectomy

Name some triggers for stress incontinence

Coughing
Laughing
Sneezing
Exercise
Anything that increases abdominal pressure

Describe the management of stress icontinence

Conservative: avoid fizzy, caffeinated drinks, pelvic floor exercises
Medical: Duloxetine
Surgical: GS: mid urethral slings(minimally nvasive, done as outpatients)

Name some risk factors for urge incontinence

Recurrent UTI
High BMI
Increasing age
Smoking
Caffeine

Describe the management of urge incontinence

Conservative: Bladder training, avoid alcoholic/caffeinted/sugary drinks
Medical: anticholinergics: oxybutinin, tolterodine, fesoterodine
Surgical: bladder instillation, sacral neuromodulation

Name a side effect of tolterodine

Increased risk of delirium

Name the causes of overflow incontinence

Underactivity of detrusor muscle(e.g from nerve damage) or if urinary outlet pressures are too high(constipation, prostatism)

What is functional incontinence?

Urge to pass urine but can't access facilities so experience incontinence

Name some causes/risk factors for functional incontinence

Sedating meds
Alochol
Dementias

What is quamous cell carcinoma?

Locally invasive malignant tumour of epidermal keratinocytes
With invasion of basement membrane as it is a cancer

Name some risk factors for SCC

Excessive exposure to sunlight/UV light
Actinic keratosis and Bowen's disease-> predisposing lesions
Genetics: xeroderma pigmentosum
Immunosuppresion
Smoking
Old age
Male

How might patients with SCC present?

Keratinised, scaly irregular nodules
Might be ulcerating or have everted edges
Often in sun exposed areas
Usually slow growing(months)
Pain, tenderness, bleeding
Complicaotins for local invasion-distant metastases is rare

How is SCC diagnosed?

Excision biopsy with 4mm margin
Might require 6mm margin if high risk

Name some features of a possible SCC that make it more high risk

>2cm diameter
Located on ear, lip, hands, feet or genitals
Elderly or immunosuppressed
Histology: poor differentiation, blood/nerve involvement, SC tissue invasion

How is SCC treated?

Surgical excision
Radiotherapy may be needed
Lifestyle to prevent further lesions-> sunscreen

What is the prognosis for SCC

5 year survival of 99% if detected early

Name some poor prognostic factors for SCC

Poorly differentiated
>2cm diameter
>4mm deep
Immunosuppression

How can constipation be classified?

Primary: no organic cause: dysregulation of function of colon/anorectal muscles
Secondary: diet, medications, metabolic, endocrinee, neuro, obstruction

What criteria is used for classifying constipation?

Rome 6 criteria

Describe the Rome 6 criteria for constipation

<3 bowel movements/week
Hard stool in >25% of movements
Teenesmus in >25% of movements
Increased straining in >25% of movements
Need for manual evacuation

Any or all of them can constitute a diagnosis of constipation

Name some risk factors for constipation

Increasing age
Inactivity
Low calorie diet
Low fibre diet
Certain medications
Female

Name some possible causes of constipation

Inadequate fibre or fluid intake
Behavioural: inactivity of avoidance of defaecation
Electrolyte distrubances like hypercalcaemia
Drugs: opiates, CCBs, antipsychotics
Neurological: spinal cord lesions, Parkinson's, diabetic neuropathy
Endocrine-> hypothyroidism
Colon disease-> strictures/cancer/obstruction
Anal disease-> fissures

Name some red flag associated features of constipation

ALARMS

Anaemia
Lost weight
Anorexia
Recent onset
Melaena/bleeding
Swallowing difficulties

What investigations might be done in a patient with constipation?

Constipation/diarrhoea+ weight loss+ >60yrs-> 2wwk wait urgent CT/US to rule out pancreatic cancer
Often no need for further ix
PR exam
Stool sample: mcs, ova, cysts, parasites
FIT testing
Faecal calprotectin
Bloods: anaemia, hypercalcaemia, hypothyroidism
Barium enema if suspicion of impaction/rectal mass
Colonoscopy-> lower GI malgnancy

Describe the management of constipation

Conservative: dietary imrpovements and increase exercise
Laxatives

What are the different types of laxatives

Bulking agents
Stool softeners
Stimulants
Osmotic laxatives
Phosphate enemas

Give an example of a bulking agent

Ipsaghula husk

How do bulking agents work?

Increase faecal bulk and peristalsis

When might bulking agents be contraindicated?

Dysphagia
GI obstruction
Faecal impaction

Name a side effect of bulking agents

Cramps

Give an example of a stool softener

Docusate
Macrogol

How do stool softeners work and when might they be used

Soften bowel movements
Good for fissures

When are stool softeners contraindicated?

IBD
Ileus
Risk of inttestinal perforation

Name some side effects of stool softeners

Flatulence
Nausea

Give an example of a stimulant laxative

Senna
Biisacodyl

How do stimulant laxatives work?

Increase intestinal motility

When might stimulant laxatives be contraindicated?

Obstruction
Colitis

Give a side effect of stimulatn laxatives

Cramps

Give an example of on osmotic laxative

Lactulose
Movicol

How do osmotic laxatives work?

Retain fluid in the bowel
Decrease NH3

Give a side effect of osmotic laxatives

Electrolyte imbalances
Diarrhoea

What must be done before a phosphate enema?

DRE first
Will cause rapid bowwel evacuation

Give some contraindications to a phosphate enema

Renal faioure
Heart failure
Electrolyte abnormalities

Give some side effects of a phosphate enema

Abdominal cramps
Dehydration

Define malnutrition

BMI<18.5 OR
Unintentional weight loss >10% in the last 3-6 mths OR
BMI<20 and unintentional weight loss >5% in the last 3-6 mths

How is malnutrition diagnosed?

Malnutrition Universal Screen Tool (MUST)
Takes into account BMI, unplanned weight loss score and acute disease effect
Should be done on admission of if there is cause for concern
Categorises patients into low, medium and high risk

How is malnutrition managed?

Dietician support if patient is high risk
'Food-first' approach with clear instructions(add full fat cream to potatoes etc)
Oral nutritional supplements between meals

What is re-feeding syndrome?

Caused by reintroduction of glucose into the body after a period of malnutrition or fasting

Describe the pathophysiology of re-feeding syndrome?

Reintroduction of glucose-> insulin secretion resumes-> shift in electrolytes

How might patients with re-feeding syndrome present?

Low phosphate: weakness, resp failure, delirium, seizures
Low magnesium: muscle weakness, arrhythmias, NM excitability
Low potassium: weakness, paralysis, cardiac arrhythmias
High glucose: diabetes sx: increased thirst, urination, fatigue, blurred vision

How is re-feeding syndrome managed?

Monitoring and correctin of electrolyte imbalances
Slow reintroduction of food and fluids to avoid sudden shiffts in electrolytes
Thiamine replacement for at risk patients to prevent Wernicke's encephalopathy

Name some risk ffactors for non-accidental injury

Caergive substance abuse
Caregiver mental health issues
Socioeconomic disadvantage

How might elderly patients with non accidental injury ppresent-history?

Delayed presentation followwing injury
Inconsistencies in caregiver's narratives
Unwitnessed injuries
Evidence of drug/alcohol use

How might elderly patients with non accidental injury present-examination?

Injuries of varying ages
Subconjunctival/retinal haemorrhages
Bruises on arms, legs, or face consisten with grippping, burns, scalds

Name some differentials for non accidental injury

Accidental injury
Bleeding disorders
Haematological malignancy

What investigations might be done if non accidental injury is suspected?

Radiology: comprehensive skeletal survey(rib fractures, skull, finger, clavice etc)
Bloods: organic causes like clotting problems and blood cancers

How should non accidentl injury be managed?

Report suspicions to informed senior or safeguarding lead
Measures: admit and ensure safety of anyone else in the home
Treat other injuries
Document everything
Contact social care liaison

What is a DoLS?

Procedure used by law when necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment/care to keep them safe from harm

How must a DoLS be authorised by?

Supervisory authority(e.g. local authority)

What conditions must be met to put a DoLS in place?

>18yrs and mental disorder
In hospital or care home
Pt lacks capacity to decide for themselves about the roposed restrictions
Proposed restrictions in person's best interest and would deprive person of their liberty
Not suitablee for detention under the MHA

What is Power of Attorney

Legal document that nominates another person to make decisions on their behalf related to financial/property or health/welfare

What is an advanced decision?

Legally binding document to ensure an individual can refuse a specific treatment(s) they don't want in the future

What criteria must be met for an advanced decision to be put into place?

Valide(made when person had capacity)
Applicable(wording specific to medical decision)
>18 yrs and fully informed wheen made
Not made under duress or influence of other people
Writeen down, signed and witnessed(if it concerns life saving treatment)

What does an advanced decision cover?

Refusal of treatments including life sustaining treatments
Can't refuse basic care, food/drink by mout, measures designed purely for comfort(painkillers) or treatment of a mental health disorder if sectoined under the MHA
Can't demand specific treatment/somethign illegal

What is an advanced statement?

Statement of wishes and care preferences
Not legally binding by itself but legally must be taken into account when making a 'best interests' decision

What creiteria must be met to make an advanced statement?

Can be made verballyy butbetter written down for documentation
Copies can be given t anyone like GPs, carers, relatives

What kind of things might be covered in n advanced statement?

Religious/personal views and how these relate to care
Food preferences
Info about dialy routine
People who youw ould like to be consulted when best interest decisions are being made on your behalf(not the same as creaitng a lasting power of attorney)

What is osteoporosis?

Systemic skeletal disease characterised by decreased bone mass and altered micro-architecture of bone tissue resultin in increased bone fragility and fracture risk

Describe the pathophysiology of osteoporosis

Primary: post menopausal(Type 1) and age related(type 2)-most commmon
Secondary: hyperthyroidism/hyperparathyroidism/alcohol abuse/immobilisation
Increased bone breakdown by osteoclasts and decreased bone formation by osteoblasts

What genes are involved in osteoporosis?

Collagen 1A1
Vitamin D receptor
Oestrogen receptor gene

How does oestrogen deficiency result in osteoporosis?

Increases number of remodelling units
Premature arrest of osteoblastic synthetic activity and trabeculae perforation
Loss of resistance to fracture

How do glucocorticoids cause osteoporosis?

Increase turnover atate initially(increased fracture risk in first 3 months)
The decreased turnover rate with net loss due to decreased synthesis by osteoblasts
Usually when used minimum 10mg OD for >3 months

How does ageing contribute to osteoporosis?

Increased turnover at the bone/vascular interface with cortical bone-> weak structure for stresses in long bones9trabeculazation of cortical bone)

Name some risk factors for osteoporosis

SHATTERED

Steroid use
Hyperthyroidism/hyperparathyroidism
alcohol and smoking
thin: BMI<22
testosterone deficiency(men wwith long term androgen deprivation therapy for prostate cancer)
early menopause
renal/liver failure
erosive/inflammatory bone disease
diabetes

Also family history

How do patients with osteoporosis present?

Pathological or fragility fractures(often from a fall at first
Most commonly vertebral compression fractures of appendicular fractures

What are the most common frfactures for patients with osteoporosis?

Vertebral compression fractures
Appendicular fractures(proximal femur/distal radius)

How do patients present with a vertebral fracture?

Sudden episode of acute back pain on rest/bending/lifting
restricted spinal felxion and intensified pain with prolonged standing
Dowager's hump: thoracic kyphosis-. anterior thoracic spine
Paravertebral muscle spams and tenderness on deep palpation

How do patient with appendicular fractures present?

NOF: hip pain, inability to weight bear, shortened and externally rotated leg
Colles: fall on outstrtched arm: wrist pain and decreased range of motion

What is the gold standrad for diagnosing osteoporosis?

DEXA sacn(dual energy x-ray absorptiometry)

Can also use x-rays/MRI for suspected vertebral/other fractures

How might you identify secondary causes of osteoporosis?

History and full exam
FBC, U&Es-Creatinine, calcium phosphate TFTs
LFTs
25OH vit D and 1-25 OH vit D
Serum testosteerone and prolactin
Lateral radiographs of thoracic and lumbar spine
Protein immunoelectrophoresis and urinary Bence Jones proteins

Name some differentials for osteoporosis

Osteomalacia: similar but also generalised bone pain and myopathy
Paget's: bone pain, joint pain, bone deformities, neuro complications
Malignancies: myeloma, lymphoma, metastatic/primary bone disease
Secondary causes: hyper(para)thyroidism, mastocytosis, Cushing's, sickle cell

For a patient with osteoporosis, what would their calcium, phosphate, ALP and PTH look like?

All normal

For a patient with osteomalacia, what would their calcium, phosphate, ALP and PTH look like?

Low calcium
Low phosphate
High ALP
High pTH

For a patient with Paget's, what would their calcium, phosphate, ALP and PTH look like?

Normal calcium
Normal phosphate
High ALP
Normal PTH

How should you interpret DEXA scan scoring?

T>-1: normal
-1>T>-2.5: osteopenia
T<-2.5: osteoporosis

How is osteoporosis diagnosed?

DEXA scan and T score

What scoring tool is used to determine the risk of fracture in a patient with osteoporosis?

FRAX score
Estimates 10 year probability of a major osteoporotic fracture

What factors are used when calculating FRAX score?

Age: 40-90yrs
Gender
Previous fracture
Parental hip fracture
Smoking
Gluccocorticoid use(>3 months at >5mg OD)
Rheumatoid arthritis
Secondary osteoporosis causes
Alcohol consumption
BMD

How is FRAX score interpreted?

<10% :normal
10-20%: osteopenia
>200%: osteoporosis

How is osteoporosis managed?

Lifestylee: decrease risk factors
Bisphosphonates
Denosumab

What lifestyle modifications might be suggested in a patient with osteoporosis?

Decrease risk factors(smoking etc)
Increase calcium and vitamin D intake
Increase weight bearing and muscle stengthening exercises

When might bisphosphonates be used as a treatment?

T score<-2.5 OR
-1->-2.5 with a FRAX >20%

How do bisphosphonates work?

Adhere to hydroxyapatite and inhibit oscteoclasts

Give some examples of bisphosphonates and how they are used

Oral alendronate and risedronate(1 weekly doses)
Xoledronic acid(once a year infusion)

How should bisphosphonates be taken?

On an empty stomach with water and remain upright for at least 30 minutes afterwards

Name some side effects of bisphosphonates

Oesophagitis
Dyspepsia

What is denosumab and when is it used?

Monoclonal antibody
Used for extensive osteoporosis

How is denosumab administered?

SC injection every 6 months

How does denosumab work?

Anti-resorptive agent that increases BMD and decreases fracture risk at spine

Name some side efffects of denosumab

Limited mobility
Increased fracture risk
Depression
Pain
Complications of medication

What systems are required to function to have a normal gait?

Neurological: basal ganglia and cortical basal ganglia loop
MSK: appropriate tone and strength
Senses: sight, sound and sensation(including fine touch and proprioception)

Name some risk factors for falls

lower limb muscle weakness
Vision problems
balance/gait disturbances
polypharmacy
postural hypotension
psychoactive drugs
incontinence
>65 years
fear of falling
depression
cognitive impairment

Name some drugs that can cause postural hypootension

Nitrates
Diuretics
Anticholinergics
Antidepressants
Beta blockers
Levodopa
ACE inhibitors

Name some drugs that can cause falls through mechanisms other than postural hypotension

benxos
antipsychotics
opiates
anticonvulsants
codeine
digoxin
sedative agetns

What investigations might be done in patients who have had a fall?

Full hx, risk assessment and examination
Bedside: Obs, BP, glucose, urine dip, ECG
Bloods: FBC, U&Es, LFTs, bone profile
Imaging: x-rays of injured limbs, CT head, cardiac echo

Describe the management of patients with falls

'Turn 180 test' or 'Timed get up and go' test
Consider MDT assessment
Treat underlying cause
Manage risk factors
Lifestyle/home changes

When should an MDT assessment be considered in patients with falls?

>65 yrs with:

>2 falls in the last 12 months
Fall requiring medical treatment
Poor performance or failure to complete above tests

What is delirium?

Acute and fluctuating disturbance in attention and cognition, often accompanied by a change in consciousness

What are the 3 subtypes of delirium?

Hyperactive: increased psychomotor activity, restlessness, agitation and hallucinations
Hpoactive: lethargy, reduced responsiveness and withdrawal
Mixed: features of both hyper and hypo

Descrieb the epidemiology of delirium

Common
Elderly
Incidence increases with age, severity of illness and pre-existing cognitive impairment

Describe the aetiology of delirium

DELIRIUMS

Drugs and alcohol
Eyes, ears and emotional disturbances
Low output state(MI, ARDS, PE, CHF, COPD)
Infection
Retention(urine or stool)
Ictal
Under-hydration or under-nutrition
Metabolic(electrolyte imbalances, thyroid disorders, Wernicke's
Subdural haematoma, sleep deprivation

Name some drugs that can cause delirium?

Anti-cholinergics
Opiates
Anti-convulsants
Recreational

Name some symptoms of delirium

Disorientation
Hallucinations
Inattention
Memory problems
Change in mood or personality
Sundowning-> worse agitation/confusion in late afternoon/evening
Disturbed sleep
Hpoactive can be easily misssed

Give some differential diagnoses for delirium

Dementia
Psychosis
Depression
Stroke

How is delirium diagnosed/assessed?

4AT and CAM: tools
Bedside: bladder scan, review meds, ECG, urine MCS
Bloods: FBC, U&E,LFTs, TFTs, blood cultures
Imaging: CXR, US, neuroimaging if suspected cause

Describe the management of delirium

Treat unerlying cause
Good lighting, regular sleep-wake cycle, regular orientation and reassurance, glassess and hearing aids if needed
If severely agitated: haloperidol/lorazepam, olanzapine as last resort due ot side effects
Don't give haloperidol for Parkionsonism(blocks dopamine receptors)

Name some factors favouring delirium over dementia

Acute onset
Impairment of consciousness
Fluctuation of symptoms(worse at night, periods of normality)
Abnormal perception(hallucinations, illusions)
Agitation, fear
Delusions

Name some risk factors for delirium

Age >65 yrs
Backgound of dementia
Significant injury(hip fracture)
Frailty or multimorbidity
Polypharmacy