Session 9 Dementia And Delirium - Confusion In The Elderly Patient

Question 1

What are the 5 causes of confusion?

Answer 1

1. Delirium
2. Depression
3. Dementia
4. Drugs
5. Metabolic

Question 2

Define delirium

Answer 2

Acute change in consciousness and cognition

Question 3

Define dementia

Answer 3

Cognitive decline due to disease of the brain

Question 4

What is dementia? (Key points)

Answer 4

• A decline in higher cortical function
• Usually progressive
• Leading to impairment of memory, intellect and personality
• A resulting failure of the individual to cope with the everyday affairs of life

Question 5

What age is the cut off for classing dementia as early onset or late onset dementia?

Answer 5

65 years old

Question 6

What are the 5 types of dementia?

Answer 6

1. Alzheimer’s dementia (most common cause of dementia)
2. Dementia with Lewy Body
3. Vascular Dementia
4. Fronts-Temporal Dementia
5. AIDS-Dementia Complex

Question 7

What simple tests could you perform to assess cognitive function in a GP setting?

Answer 7

• ask patient to recall 3 items that you have previously told them
• ask patient to draw a clock face
• ask patient to work out some simple sums
• ask patient for their name and today’s date

Question 8

What examinations/assessments can you use to assess cognitive function?

(The form things)

Answer 8

Mini mental state examination (MMSE)

Montreal Cognitive Assessment (MOCA)

Question 9

What macroscopic changes would you see in Alzheimer’s Dementia?

Answer 9

Global atrophy of brain lobes (most commonly temporal) - frontal and parietal also but less in the occipital lobe

Sulcus widening

Enlarged 3rd and 4th interventricular spaces

Question 10

What microscopic changes can be seen in Alzheimer’s dementia?

Answer 10

Senile amyloid plaques
- derived from proteolytic breakdown from b-amyloid precursor protein

Neurofibrillary Tau tangles

These increase acetylcholinesterase enzyme which leads to increased breakdown of ACh resulting in neuronal death

Question 11

What genetic markers can be seen with early onset Alzheimer’s Dementia?

Answer 11

Beta-amyloid precursor protein (b-APP)

Presenilin 1
Presenilin 2

• these are involved with the breakdown of the amyloid precursor protein

Question 12

What gene marker can be seen in late onset Alzheimer’s dementia?

Answer 12

Apolipoprotein E gene

Question 13

What are the classical presenting complains with Alzheimer’s dementia?

Answer 13

• deterioration of memory (most common)
• deterioration in spatial navigation
• difficulty in executive functions:
• language
• visuospatial functioning
• calculation
• affecting activities of daily living

Question 14

What are the two classes of drugs to treat Alzheimer’s dementia?

Answer 14

1. AChE inhibitors

2. Memantine

Question 15

Describe the pathophysiology of Lewy Body Dementia

I.e. what are Lewy bodies like

Answer 15

Presence of Lewy bodies

• aggregation of alpha-synuclein protein
• spherical in shape
• found intra-cytoplasm
• deposits at substantia Nigra, temporal lobe, frontal lobe and cingulate gyrus

Question 16

What are the three core clinical features of Lewy Body Dementia? (The presenting complaints!)

Answer 16

1. Fluctuating cognition with variations in attention and alertness
2. Visual hallucinations
3. Features of Parkinsonism - shuffling gait, flexed posture (NOT tremor or rigidity)

NB: Parkinson’s dementia would initially prevent with rigidity and tremor then later would have features of dementia

Question 17

Treatment of Lewy Body Dementia?

Answer 17

1. AChE inhibitors

2. Memantine

Question 18

Describe the pathophysiology of frontal-temporal dementia

Peak onset?

Atrophy of which lobes?

Answer 18

2nd most common cause of EARLY-onset dementia

Peak onset = 55-65 years old

Atrophy of frontal and temporal lobes

Question 19

Classic presenting complaints of fronto-temporal dementia?

Answer 19

• symptoms are based on lobe dysfunction
• altered behaviour, personality and social conduct
• appear disinhibited and apathetic
• disorders of language - EXPRESSIVE dysphasia (cant find the right words but can understand what is being asked)
• primitive reflexes
• short/long-term memory impairment
• disorder of language - RECEPTIVE dysphasia (cant understand the question but answer in fluent jibberish)

Question 20

What are the risk factors of vascular dementia?

Answer 20

hypertension
Smoking
Diabetes
Vascular disease

Question 21

Why does vascular dementia occur?

Answer 21

Due to cerebrovascular disease (ischaemic or haemorrhagic)

Question 22

Classic presenting complain for vascular dementia?

Answer 22

A step wise deterioration of cognitive function with focal neurological symptoms

For every TIA there is a small decline

Question 23

Treatment of vascular dementia?

Answer 23

More about managing the risk factors as opposed to pharmacological management

Question 24

Describe the pathophysiology of AIDS Dementia Complex (ADC)

Answer 24

• increased prevalence
• HIV-infected macrophages will ent the brain and cause indirect damage to neurones
• insidious onset but once established it progresses rapidly!

Question 25

Classic presenting complaint for AIDS dementia complex?

Answer 25

Cognitive impairment Psychomotor retardation Tremor Ataxia Dysarthria Incontinence

Question 26

Treatment for AIDS dementia complex?

Answer 26

Anti-virals

Question 27

What are some common investigations you should carry out for all suspected dementia cases?

Answer 27

* need to be done within 6 months f recording a new diagnosis of dementia - FBC - U&E - ESR or CRP - TFTs - LFTs - Random blood sugar - vitamin B12 and folate Syphilis test if risk identified in history

Question 28

What model should you follow when starting a management plan for all dementia cases?

Answer 28

Bio-psycho-social model Includes addressing things like: * mobility problems * activities of daily living * ability to learn new skills * financial problems

Question 29

What is the definition of delirium?

Answer 29

Acute onset of altered mental status and fluctuating course Inattention Disorganised thinking and confusion Altered level of consciousness - key in differential

Question 30

What are the 3 types of delirium?

Answer 30

1. Hypoactive delirium 2. Hyperactive delirium 3. Mixture of both (most common)

Question 31

What are the causes of delirium?

Answer 31

Drugs toxicity * withdrawal Endocrine * hyper or hypothyroidism * addison’s / cushing’s Liver failure Intracranial: Stoke, haemorrhage, cerebral abscess and epilepsy Renal failure (build up of toxins in blood) Infections: pneumonia, UTI, sepsis and meningitis Urinary retention / faecal retention (constipation) Metabolic * electrolyte imbalance * hypoxia

Question 32

What investigations could you perform if you suspect delirium?

Answer 32

Blood tests * FBC * U&E * CRP * TFTs * LFTs * random blood sugar * blood culture (if septic) Bedside tests * urine dip +/- culture * oxygen saturation Radiological tests * CXR * CT head PLUS review current drug history

Question 33

How would you treat delirium?

Answer 33

Treat underlying cause - important! Calm environment Rehydrate Haloperidol (antipsychotic medication) - only if needed!

Question 34

Compare dementia and delirium 6 things

Answer 34

Dementia vs Delirium * slow onset vs rapid onset * steady decline vs fluctuant course * hallucinations rare vs hallucinations common * speech often slow vs speech slow or fast * normal GCS vs reduces GCS * clear consciousness vs impaired consciousness

Question 35

How to assess a patient who is unconscious?

Answer 35

Check breathing / central pulse Lie them on their left side Call for help Options to assess consciousness * sternal rub * trapezius squeeze * fingernail pressure test Ensure patient is stable Assess GCS