Geriatics: Confusion

Question 1

What should we think about when we refer to someone as being confused?

Answer 1

Their cognitive ability

Question 2

What are the 6 neurocognitive domains?

Answer 2

• Complex attention
• Perceptual-motor function
• Language function
• Executive function
• Learning/memory
• Social cognition

Question 3

Why is assessing cognition important?

Answer 3

• May be relevant to current medical problems
• Associated with increased risk death/increased LOS/discharge to care home
• May need to alter communication/information given/involvement of family members
• Help you decide regarding capacity
• May alter appropriateness of tests/investigations/certain treatments
• May be able to improve it!

Question 4

What is key in diagnosing cognitive impairment?

Answer 4

History

Question 5

What is important to establish when taking a history in cognitive impairment?

Answer 5

Onset

• When
• How rapid

Course

• Fluctuating?
• Progressive decline

Associated features

• Other illness
• Functional loss

Question 6

What are the key features of delirium?

Answer 6

Disturbed consciousness
-Hypoactive/hyperactive/mixed

Change in cognition
-Memory/perceptual/language/illusions/hallucinations

Acute onset and fluctuant

Question 7

What features commonly occur in delirium

Answer 7

• Disturbance of sleep wake cycle
• Disturbed psychomotor behaviour
• Emotional disturbance

Question 8

What precipitates delirium?

Answer 8

• Infection (but not always a UTI!)
• Dehydration
• Biochemical disturbance
• Pain
• Drugs
• Constipation/Urinary retention
• Hypoxia
• Alcohol/drug withdrawal
• Sleep disturbance
• Brain injury
• Change in environment

Question 9

Why is it important to know about delirium?

Answer 9

• Very common particularly in elderly
• Commonest complication of hospitalisation
• Massive morbidity and mortality

Question 10

How is delirium diagnosed?

Answer 10

4AT score

Question 11

What should you de when you diagnose delirium?

Answer 11

• Explain the diagnosis

- Treat the cause (establish from history and exam, TIME bundle)

Question 12

How should a patient with delirium be managed ?

Answer 12

• Re-orientate and reassure agitated patients (USE FAMILIES/CARERS)
• Encourage early mobility and self-care
• Correction of sensory impairment
• Normalise sleep-wake cycle
• Ensure continuity of care (avoid frequent ward or room transfers)
• Avoid urinary catheterisation/venflons

Question 13

How should delirium be managed pharmacologically?

Answer 13

• Drug treatment of delirium is usually not necessary
• STOP BAD DRUGS (including anticholinergics and sedatives)
• Sedatives should only be used if the patient is a danger to themselves or others or is severely distressed

Question 14

What is dementia?

Answer 14

Acquired decline in memory and other cognitive functions in an alert person sufficiently severe to cause functional impairment and present for more than 6 months

Question 15

What are the types of dementia?

Answer 15

• Alzheimers
• Vascular dementia
• Mixed Alzeimers/Vascular
• Dementia with Lewy Bodies
• ‘Reversible’ causes

Question 16

How does Alzheimer’s present?

Answer 16

• Slow, insidious onset
• Loss of recent memory first
• progressive functional decline

Question 17

What are the risk factors for Alzheimer’s?

Answer 17

• Age
• Vascular risk factors
• Genetics

Question 18

How does vascular dementia present?

Answer 18

• Classically step-wise deterioration
• Executive dysfunction may predominate rather than memory impairment
• Associated with gait problems often

Question 19

What are the risk factors for vascular dementia?

Answer 19

Often have known vascular risk factors

• T2DM
• AF
• IHD
• PVD

Question 20

How does dementia with Lewy bodies present?

Answer 20

• May have parkinsonism
• Often very fluctuant
• Hallucinations common
• Falls common

Question 21

How does fronto-temporal dementia present?

Answer 21

Onset usually earlier

Early symptoms differ from other dementias

• Behavioural changes
• Language difficulties
• Memory is often unaffected early on

Usually lack insight into their difficulties

Question 22

How is dementia diagnosed?

Answer 22

• MMSE
• MOCA
• History

Question 23

What are the problems with the tests used in the diagnosis of dementia?

Answer 23

• Can be culturally/ generationally/ intellectually specific

- Can be falsely reassuring and should therefore be used as monitoring tools

Question 24

What non-pharmacological therapy is there for dementia?

Answer 24

• Support for person and carers
• Cognitive stimulation
• Exercise
• Environmental design
• Avoiding changes in environment/social support etc
• Advanced care planning

Question 25

What pharmacological forms of management is there for dementia?

Answer 25

Cholinesterase inhibitors - Mainly used in Alzheimer (Galantamine licensed in mixed dementia, Rivastigmine in Dementia with Lewy Bodies) - Not a cure Anti-psychotics - Should be avoided If possible - Start low and go slow

Question 26

What reversible causes of dementia are there?

Answer 26

- Hypothyroidism - Intracerebral bleeds/tumours - B12 deficiency - Hypercalcaemia - Normal pressure hydrocephalus - Depression

Question 27

What is capacity?

Answer 27

The capability of someone to make decisions about their care

Question 28

If someone does not have capacity, who may have the ability to make decisions for them?

Answer 28

Welfare POA or guardian