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Lecture

MEDI3004 MENTAL HEALTH ROTATION -YEAR 3 MBBS. Topic 6 - Delerium and Dementia.docx

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Department
Medicine
Course Code
MEDI2022
Professor
Associate Professor Jane Turner

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6. DELERIUM AND DEMENTIA DELIRIUM Delirium: acute or subacute brain failure in which impairment of attention is accompanied by abnormalities of perception and mood.  Confusion is worse at night  Sleep reversal (i.e. sleep during day)  Thought and speech incoherent, memory impaired and misperceptions occur  Episodic visual hallucinations and persecutory delusions may occur  Patient may be frightened, suspicious, restless and uncooperative CRITERIA A. disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition. RISK FACTORS  Hospitalisation (incidence 10-40%)  Severe illness (cancer, AIDS)  Nursing home residents (incidence 60%)  Pre-existing cognitive impairment or  Childhood (e.g. febrile illness, brain pathology anticholinergic use)  Recent anesthesia  Old age (especially males)  Substance abuse CAUSES The most frequent reversible cause is medication  Narrow therapeutic index  Strong anticholinergic  Potent opiate/analgesic  Psychotropics in general  Newly commenced especially in last 4-8 weeks  Multiple drugs may have small effects which when added are toxic (potential polypharmacy) Others (I WATCH DEATH) Cause Examples I Infectious Encephalitis, meningitis, UTI, pneumonia, sepsis W Withdrawal Alcohol, barbituates, benzodiazepines A Acute metabolic disorder Hepatic failure, renal failure, dehydration, electrolyte imbalance T Trauma Head injury, postoperative C CNS pathology Trauma, Tumour, Abscess, SAH, Epilepsy, Stroke, Parkinson’s H Hypoxia Anaemia, CHF, PE D Deficiencies in vitamins Thiamin, nicotinic acid, B12, folic acid E Endocrinopathies Hypothyroidism, Cushing’s, diabetes, parathyroid A Acute vascular insults shock, vasculitis, hypertensive encephalopathy T Toxins Substance use, withdrawal, sedatives, opioids, anesthetics, anticholinergics, anticonvulsants, dopaminergic agenets, steroids, insulin, glyburide, antibiotics, NSAIDs H Heavy metals arsenic, lead, mercury Miscellaneous Constipation, pain, frequent moves in severe dementia, postoperative state CLINICAL FEATURES Cognitive Impairments  Acute change and fluctuation of mental state  Disorientation to time and place  Speech/language disturbances e.g. dysarthria, dysnomia, dysgraphia  Alertness impaired  Distractibility Psychotic Sx  Visual hallucinations and delusions usually related to these Affective Sx  Psychomotor agitation/retardation  Anxiety, fear, depression, irritability, anger, euphoria, apathy Other  Sleep-wake cycle inversion  Lucid intervals DIFFERENTIAL DIAGNOSIS Disturbances of emotion, cognition or behavior in older people that produce significant disability or risk are commonly due to:  Delerium  Dementia  Major Depression  Side effects of prescribed Drugs Dementia Delirium Major Depression Definition A general loss of cognitive An acute, transient disturbance Pervasive loss of joy abilities, including impairment of consciousness accompanied emerging over weeks of memory as well as one or by a change in cognition, and more of the following having a fluctuating course.  Aphasia, Apraxia or Agnosia  Executive Dysfunction  No impairment of consciousness History &  Insidious onset  Raid onset  Onset over weeks Timing  Long duration  Often short duration  Worse at a time of  Chronic, usually progressive  Acute (and potentially the day but (irreversible) reversible) predictably slow e.g.  Often doesn’t fluctuate  Fluctuating course during diurnal mood that day variation Mental  Impairment of intellect,  Deficit in attention, alertness State memory and personality and memory  Attention often normal  Agitation  Memory impairment  Abnormal perceptions   orientation in place and (hallucinations), thought time patterns and abnormal  mental state can be tested, beliefs (delusions) but poor result  Often difficult to test mental state Aetiology  Alzheimers  See purple box    Mixed  Vascular Dementia  Lewy Body Dementia  Others DIAGNOSIS The confusion Assessment Method (CAM) Diagnostic Algorithm 1. Acute Onset and Fluctuating Course Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? 2. Inattention: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? 3. Disorganised Thinking: Was the patient’s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. Altered Level of Consciousness: Any answer other than “alert” to the following question: Overall, how would you rate this patient’s level of consciousness? (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult or arouse], or coma [unarousable])? * The diagnosis of delirium by CAM requires the presence of Features 1 & 2 and either 3 or 4. MANAGEMENT Diagnostic Work Up Investigations Assessment  History  Observations: vital signs, oximetry, glucometry, dipstick IDC sample, lying and standing BP  Review obs chart, medication chart and hospital record  Examine cardiovascular, respiratory, CNS and palpate bladder  Note results of simple cognitive testing e.g. MSQ and serial 3s from 20 First Line FBC, e/LFT, Screen for occult infection (MSU, CXR, selected cultures) Second Line CT head, ECG, inflammatory markers, TSH, PT/INR, s. levels Third Line Lumbar puncture, EEG, HIV, TPHR Management  Initial Mx o Address obvious causes o Cease/withhold newly commenced medication if other causes seem unlikely o Supportive care:  Maintain: nutrition, hydration, electrolyte balance and monitor vitals  Avoid: dehydration, malnutrition, immobility, catheters and restraints, poor sleep, sensory deprivation, polypharmacy  Environmental control o Environment control: quiet, well lit o Optimise hearing and vision o Nursing care of people with cognitive impairment o Family member present for reassurance and re-orientation o Calender, clock for orientation cues Medications  Haloperidol is standard.  Avoid regular antipsychotics, other psychotropic use and anticholinergic medications Type Route 1 Line 2ndLine Statim Oral Haloperidol 0.5 to 2mg orally. If haloperidol is inappropriate give Continue non-drug approaches, if Risperidone 0.25-0.5mg oral little/no effect after 60 minutes, For alcohol or benzodiazipine withdrawal repeat haloperidol 0.5-2mg oral give diazepam IM Haloperidol 0.5 to 1.5mg IM as Where haloperidol is inappropriate  * avoid a single dose. Repeat as needed Olanzepine 2.5mg IM in after 30 mins to maximum 5mg Avoid IM midazolam when no monitoring patients haloperidol total. Usually no available. >65 benztropine needed or recommended Regular Oral Haloperidol 0.25-0.5mg bd. No Risperidone where parkinsonism is a more than 3mg/day total concern (no more than 1mg/day in frail including PRN on frail elderly elderly Use diazepam when benzo/alcohol withdrawal suspected as the main cause of delirium Small regular doses IV haloperidol ca be used in ICU PRN Haloperidol 0.5mg bd PRN. Total max dose including regular 3mg/day. Continue only when it has been shown to work for that person. Indication e.g. severe agitation, anxiety, aggression, delusions and/or hallucinations Benzodiazepines  Use in benzo and alcohol withdrawal delirium  Temazepam can normalize sleep  S/Es: Respiratory depression in elderly (especially if an high fl2w O )  Contraindicated in significant liver disease DEMENTIA Risk Factors EPIDEMIOLOGY  Prevalence in increases with age  Age o 10% of patients >65  Head trauma o 25% of patients >80  Down syndrome  Average duration from Dx to death is 8-10 years TYPES  Early onset: <65years Type Features Alzheimer’s >50%  Insidious onset of forgetfulness progressing over time  Develops to profound memory impairment with accompanying dysphasia, dyspraxia and personality change Vascular Dementia >15%  Stepwise deterioration, starts suddenly  Focal neurological signs  Imaging evidence of cerebrovascular disease  Comorbid atherosclerotic disease Mixed  Features of both Alzheimer’s and vascular dementia Lewy Body <10%  Visual hallucinations Dementia  Spontaneous motor parkinsonism  Fluctuation in mental state in the absence of a clear cause of delerium Fronto-temporal <10%  Personality change and alteration in behavior  apathetic, dementi
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