Phase 4 > Geriatrics > Flashcards

Geriatrics Flashcards

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1
Q

What is delirium?

A
  • Delirium = acute confusional state
  • Acute, fluctuating disturbance of consciousness, attention and cognition

Synonyms: acute confusion, acute confusional state, encephalopathy

Epidemiology:
* Very common in older adults
* ~50% of hospitalised patients >65
* Up to 87% of ICU patients

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2
Q

Key diagnostic features of delirium (DSM-5)?

A
  • Acute onset (hours–days)
  • Fluctuating course
  • Disturbed attention & awareness
  • Cognitive disturbance (memory, language, disorientation)
  • Evidence of an organic cause (illness, drugs, intoxication)
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3
Q

Typical onset of delirium?

A

Hours to days.

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4
Q

Hallmark cognitive feature of delirium?

A

Inattention.

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5
Q

Three subtypes of delirium?

A
  • Hyperactive: agitation, hallucinations, wandering
  • Hypoactive (often missed ⭐): drowsy, withdrawn, quiet
  • Mixed: alternating features
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6
Q

Features of hyperactive delirium?

A

Agitation, restlessness, hallucinations, wandering.

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7
Q

Features of hypoactive delirium?

A

Drowsy, withdrawn, quiet, reduced activity (often missed).

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8
Q

Most common risk factors for delirium?

A
  • Age >65
  • Dementia / cognitive impairment
  • Frailty, malnutrition
  • Sensory impairment (vision/hearing)
  • Polypharmacy
  • Alcohol excess
  • Acute illness or major injury (e.g. hip fracture)
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9
Q

Common precipitants of delirium?

A

Infection, medications (anticholinergics), metabolic disturbance, pain, constipation, urinary retention.

From head-to-toe:
* Neurological: stroke, subdural haematoma
* Cardiac: MI, AF, heart failure
* Respiratory: pneumonia, aspiration
* GI: constipation, malnutrition, bleeding
* GU: UTI, urinary retention
* Metabolic: hypo/hyperglycaemia, Na⁺, Ca²⁺, thyroid
* Medications: anticholinergics, antihistamines, TCAs
* Other: pain, infection, alcohol, sleep deprivation, new environment

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10
Q

Causes of delirum

A

PINCH ME:

  • Pain
  • Infection
  • Nutrition
  • Constipation, Urinary retention
  • Hydration
  • Medications
  • Environmental Triggers / Electrolytes
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11
Q

Pathiophysiology of delirium

A
  • Global cortical dysfunction
  • Neurotransmitter imbalance:
    • ↓ Acetylcholine
    • ↑ Dopamine

Explains:
* Anticholinergics → delirium
* Antipsychotics → severe agitation

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12
Q

Neurotransmitter changes in delirium?

A

↓ Acetylcholine + ↑ dopamine.

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13
Q

How does delirium differ from dementia?

A

Delirium is acute and fluctuating; dementia is chronic and progressive.

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14
Q

Clinical features of delirium

A

Basic:
* Memory disturbances (loss of short term > long term)
* May be very agitated or withdrawn
* Disorientation
* Mood change
* Visual hallucinations
* Disturbed sleep cycle
* Poor attention

More detailed:
Consciousness:
* Reduced awareness, drowsy or agitated

Cognition:
* Poor attention
* Memory impairment
* Disorientation
* Disorganised speech/thought

Perception:
* Visual hallucinations (common)
* Delusions, paranoia

Other:
* Sleep–wake cycle reversal
* Mood lability
* Hypersensitivity to light/sound

⚠️ Always establish baseline function (collateral history)

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15
Q

What is delirium superimposed on dementia?

A

Acute delirium occurring in a patient with underlying dementia.

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16
Q

What are the bedside cognitive tools for delirium?

A
  • Confusion Assessment Method (CAM)
    • Delirium = 1 + 2 + (3 or 4)
  • The 4A’s Test (4AT)
    • (rapid, no training)
  • Abbreviated mental test (AMT)
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17
Q

4AT assesses what?

A
  • Alertness,
  • AMT4,
  • Attention,
  • Acute change or fluctuation.
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18
Q

What Investigations are on a confusion screen?

A

Bedside:
* Obs, ECG
* Capillary glucose
* Urine dipstick

Bloods:
* FBC, U&Es, LFTs
* Calcium, CRP
* TFTs
* B12 / folate
* Drug levels
* Blood cultures

Imaging:
* CXR
* CT head (if trauma, focal signs, ↓ GCS)

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19
Q

Management of delirum

A

FIRST-LINE:
* Treat the cause: Antibiotics, fluids, relieve retention, correct electrolytes
* Non-pharmacological:
- Reorientation
- Calm environment
- Adequate hydration, pain control
- Glasses/hearing aids
- Involve family

RISK TO SLEF/OTHERS:
* Haroperidol = 0.5mg (first-line)
- Use lowest dose
- Check the QT interval with antipsychotics
* Lorazepam

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20
Q

Initial management priority in delirium?

A

Identify and treat underlying cause.

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21
Q

First-line management of agitation in delirium?

A

Non-pharmacological measures.

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22
Q

Drugs used for severe agitation in delirium?

A

Low-dose haloperidol or lorazepam (with caution).

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23
Q

Legal framework often used in delirium care?

A

Mental Capacity Act – treat in best interests.

  • Most patients lack capacity
  • Treat under Mental Capacity Act
  • Use least restrictive option
  • Consider DoLS if liberty restricted
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24
Q

Common complications of delirium?

A

Increased mortality, prolonged admission, risk of dementia.

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25
Key points: Delirium
* Hypoactive delirium is most commonly missed * Always seek **collateral history** * **Delirium ≠ dementia (but often coexist)** * **Treat cause + environment before drugs** * **Anticholinergics** = are common culprits
26
Define dementia
* **Dementia** = a **progressive, irreversible condition** causing **impairment** in **memory, cognition, personality, and communication.** * **Early-onset dementia**: Symptoms appear **before age 65.**
27
What is mild cognitive impairment (MCI)?
* Cognitive deficits greater than expected for age but not severe enough for dementia. * Independent living usually possible.
28
What is Alzheimer's disease?
* Most common type. Pathophysiology: * **Brain atrophy** * **Amyloid plaques** * **Reduced cholinergic activity** * Neuroinflammation.
29
What is vascular dementia? What are the risk factors?
* Second most common dementia * Caused by **vascular damage** + **impaired cerebral blood flow** * Risk factors: - Hypertension - Diabetes - Smoking
30
What is dementia with Lewy Bodies?
* **Cognitive decline** with **Parkinsonism**. Other symptoms: * **Visual hallucinations** * **Delusions** * REM sleep disorder * Fluctuating consciousness. ## Footnote Lewy body → hallucinations
31
What is frontotemporal dementia?
* **Younger onset**: typically affects ages **40–60**. * Mainly **frontal** and **temporal** **lobes** affected. * Presentation: - **Behavioural changes** - **Speech** **and** **language** **abnormalities**. * Can be **familial**.
32
What are some differential diagnoses for dementia (/other causes of cognitive/personality changes)?
* **Medications**: Anticholinergics (e.g., oxybutynin, antihistamines, amitryptyline) * **Psychiatric**: Depression, delirium, psychosis. * **Neurological**: Parkinson's, brain tumours, Huntington's. * **Endocrine & Nutritional**: Hypothyroidism, adrenal insufficiency, hypercalcaemia, B12/thiamine deficiencies (Wernicke-Korsakoff syndrome)
33
Wat are some modifiable risk factors for dementia?
* Regular exercise * Mental stimulation * Healthy weight * Blood pressure control * Blood glucose control
34
What are the early symptoms of dementia?
* Forgetfulness (events, names, words) * Repetitive questioning * Impaired decision-making * Reduced cognitive flexibility
35
What are some advanced symptoms fo dementia?
* **Loss of ability for self-care** * **Aphasia** (speech difficulties) * **Dysphagia → aspiration/pneumonia** * Appetite loss, weight loss * Incontinence
36
Name some memory screening tests
* 6CIT * 10-CS * Mini-Cog * MoCA
37
Investigations for dementia
* **Bloods**: FBC, U&E, LFT, CRP, ESR, thyroid, calcium, HbA1c, B12, folate. * **Mid-stream urine (MSU)** → if **infection** suspected. * **Chest x-ray** → if **lung cancer** suspected. * **Screening tests: 6CIT, Mini-Cog, MoCA.** * **Specialist testing: Addenbrooke's Cognitive Examination-Ill (ACE-lIl).** * Specialist imaging: **MRI brain.**
38
What is the specialist screening tool for dementia?
**ACE-III (Addenbrooke’s Cognitive Examination III)** * **Domains**: Attention, Memory, Language, Visuospatial, Verbal fluency * Score: 0–100 (**≤88 may indicate dementia**) * Detailed assessment (up to 90 min)
39
What is the medical management of Alzheimer's dementia?
**DONEPEZIL + MEMANTINE** * **Acetylcholinesterase inhibitors:** **donepezil**, rivastigmine, galantamine * **NMDA receptor antagonist: memantine**
40
What support and planning can be done for patients with dementia?
Planning ahead: * Lasting Power of Attorney * Advanced decisions on treatment * Future care planning
41
What are behavioural and psyhcological symptoms of dementia (BPSD)? What are the management options?
BPSD: * Depression, anxiety, agitation, aggression, disinhibition * Hallucinations, delusions, sleep disturbance Management options: * Address underlying causes. * **Environmental adjustments** * **SSRIs if depressed** * **Antipsychotics** (**risperidone**) only if necessary * **Benzodiazepines** = only for **crisis management**
42
Progression of brain atrophy in AD
Medial temporal lobe -> limbic system -> widespread throughout brain
43
Describe the onset of AD
Insidious, progresses steadily (deteriorating course over 8-10 years)
44
First line investigations for AD
* Mini Mental State Examination * MRI head (generalised atrophy with medial temporal lobe)
45
Differential diagnoses for AD
* Delirium * Depression * Vascular dementia * Dementia with Lewy bodies * Frontotemporal dementia * Parkinson's disease dementia
46
First line management for AD
* Cholinesterase inhibitor (oral rivastigmine or donepezil) * Anti-glutamate (memantine)
47
Name a cholinesterase inhibitor
* Rivastigmine * Donepezil
48
Which lobes area affected in frontotemporal dementia?
* Frontal * Temporal
49
How does frontotemporal dementia usually present?
* Disruption in **personality + social** conduct OR * Primary **language** disorder
50
What do 50% of people with frontotemporal dementia also display?
Parkinsonism
51
What specifc-protein cellular inclusions are involved in frontotemporal dementia?
Tau protein build-up → stop neuronal signalling → neuron apoptosis
52
What genetic mutation is a risk factor for frontotemporal dementia?
MAPT gene
53
What two types of motor disease are associated with frontotemporal dementia?
* Parkinsonism * Motor neuron disease
54
What are the signs and symptoms of frontotemporal lobe dementia?
- **Frontal lobe involvement →behaviour/emotional changes** - Disinhibition, emotional blunting, apathy/empathy-loss, compulsive behaviour, family/friend dissociation (argumentative/hostile behaviour) - **Temporal lobe involvement → language impairment, emotional disturbance** - Difficulty finding correct word, progressive aphasia, impaired word comprehension - **Later stages → cognitive decline** - Worsening memory, inability to learn new things, concentration loss
55
A patient presents with: * Changes in personality and social behaviour * Progressive loss of language comprehension * Memory impairment, disorientation, apraxia * Self-neglect and abandonment of social activity and contacts Possible diagnosis?
Frontotemporal dementia
56
What are the Ix for frontotemporal dementia?
* Formal cognitive testing - Frontotemporal rating scale (FRS) - MMSE (not great) * Brain MRI - Atrophy in the front and/or anterior temporal lobes - (usually left-right asymmetry)
57
When investigating frontotemporal dementia, if a brain MRI becomes back normal or intermediate. What imaging should you request? What would it show if positive?
**Brain fluorodeoxyglucose (FDG-PET) scan** * Focal hypo-metabolism in the frontal and/or anterior temporal lobes (frequently asymmetrical)
58
What is the non-pharmacological and pharmacological treatments of frontotemporal dementia?
Non-pharmacological: * Physical exercise * Occupational therapy * Increased supervision Pharmacological: * Benzodiazepine or antipsychotoc (**lorazepam**, risperidone) * SSRI (**citalopram** or sertraline) * **Trazodone** (sleep disturbances)
59
Possible complications for frontotemporal dementia
* Irresponsible/compulsive spending * Dangerous driving * Falls * Problems with family relationships
60
What protein is responsible for Lewy body dementia and where is it found?
* Alpha-synuclein protein aggregation → Lewy bodies → apoptosis * Cortex + substantia nigra
61
What are the key presentation of Lewy Body dementia?
* **Cognitive impairment** - Attention, executive, visuospatial functions, memory (later) * **Visual hallucinations**, disordered speech * **Parkinsonism** - Resting tremor - Stiffness, slow movement - Reduced facial expressions * **REM sleep behavioural disturbance**
62
Imaging for Lewy body dementia. What does it show?
* CT/MRI head * **Generalised cortical atrophy** (preservation of the medial temporal lobe (particularly the hippocampus) * CT PET
63
What are the first and second line treatments for Lewy Body dementia?
First line: * Supportive care * Cholinesterase inhibitor (rivastigmine or **donepezil**) * SSRIs (sertraline or citalopram) * Sleep disturbance → **clonazepam** * Severe motor symptoms → dopaminergic agent (carbidopa/**levodopa**) Second line: * **Memantine** (orally) * Antipsychotic (**risperidone**)
64
Name an antipsychotic
Risperidone
65
Complications of Lewy Body dementia
* (Aspiration) Pneumonia * Dysphagia * Antipsychotic sensitivity * Urinary incontinence * Falls
66
What are some causes of vascular dementia?
Cerebrovascular changes: E.g. **Infarction, haemorrhage** * **Cerebral artery atherosclerosis** * Carotid artery/heart embolisation * Chronic hypertension → cerebral arterioles sclerosis * **Vasculitis**
67
Where does the damage occur in vascular dementia?
Grey + white matter
68
What are the key presentations of vascular dementia?
- Prominent executive function deficit - Progressive stepwise cognitive function impairment - Late-onset memory impairment
69
What does damage in the frontal lobe lead to?
Executive dysfunction
70
What does damage in the left parietal lobe lead to?
* Aphasia * Apraxia * Agnosia
71
What does damage in the temporal lobe do?
Anterograde amnesia
72
Ix for vascular dementia
* **Brain CT/MRI** - Cerebrovascular lesions (**multiple cortical, subcortical infarcts**) * ECG (AF may be present) * Vitamin B12 (rule out for cognitive decline) * Carotid duplex/doppler ultrasound (reveal carotid plaques/carotid stenosis) * **Echocardiogram** (reveal cardiogenic emboli)
73
What is the management for vascular dementia?
* Antiplatelet therapy (prevent further infarction) - **Aspirin** or **clopidogrel** (orally) * Lifestyle modification * Concomitant AD → **Memantine** OR acetylcholinesterase inhibitor (donepezil or **rivastigmine**) * Vadcular risk factor control (atorvastatin) * Depression/agitation (**sertraline**)
74
How is vascular dementia characterised?
Chronic progressive multifaceted impairment of cognitive function
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