1 / 100

Delirium

Delirium. Worsens prognosis- significant mortality rate Lengthens stay in hospital- longer in bed, falls, pneumonia Increased rates of institutionalisation Potentially treatable Up to 2/3 not detected. Delirium: Clinical Features.

drago
Download Presentation

Delirium

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Delirium • Worsens prognosis- significant mortality rate • Lengthens stay in hospital- longer in bed, falls, pneumonia • Increased rates of institutionalisation • Potentially treatable • Up to 2/3 not detected

  2. Delirium: Clinical Features • Clouding of consciousness, attention, memory, executive function all affected • 2 types • Apathetic • Active, psychotic, behavioural symptoms • Symptoms worse at night

  3. Delirium:Risk Factors • Increasing age • Dementia • Sensory deficits • Previous episode • Severe comorbidity • Immobility • Sleep Disturbance • Alcohol Consumption • Operation • Dehdration • Low albumin

  4. Delirium-Medication Risk factors • Benzodiazepines • Anticholinergics • Opiates • Digoxin • Warfarin

  5. Delirium Causes • Almost anything in combination with risk factors

  6. Delirium-Tips • Sudden deterioration in mental state consider delirium • The greater the number of risk factors the more delirium is likely • Sometimes delirium can go on for weeks

  7. Delirium:Treatment • Identify and treat cause • Modify risk factors • Infections, metabolic, malignancy, cardiac, vascular • Consider hospital admission

  8. Delirium:TreatmentThe eight ates or Nice Coat • Noise abate • Illuminate • Communicate • Environment manipulate • Carer participate • Orientate • Ambulate • Thermoregulate

  9. Delirium:Medication • If hyperactive and psychotic • Antipsychotic-haloperidol • Olanzapine, quetiapine • Lorazepam

  10. The Dementias • Normal Ageing • Mild Cognitive Impairment (MCI) • Dementia

  11. The Dementias: Clinical Features • Progressive • Impairment of cognition, personality and intellect • Orientation, • Memory, • Language(dysphasia) • Ability to carry out tasks(praxias) • Recognition (agnosia)

  12. The Dementias-Executive Function Impairment • Planning • Organising • Abstract thinking • Multi tasking

  13. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD • Why are they important? • Predict carer distress and breakdown of supportive network • Predict institutionalisation • Nearly 90% of admissions to Larch

  14. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD • Mood • Anxiety as a presentation • Anxiety as a concomitant • Depression • Elation- often pre existing bipolar disorder

  15. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD • Psychosis • Delusions • Phantom lodger • Misidentifications e.g.Capgras • Persecutory

  16. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD-Psychosis • Hallucinations • Auditory- music, voices • Visual-people, animals

  17. The Dementias: Behavioural and Psychological Symptoms in Dementia- BPSD • Wandering • Agitation • Day night reversal • Verbal Aggression • Physical Aggression • Disinhibition • Apathy

  18. The Dementias: Causes • Subdural • Brain tumour • Normal pressure hydrocephalus • Hypothyroidism • Low B12/folate • Syphilis • Diabetes • Chronic infection • Uraemia

  19. The Dementias: Causes • Alzheimer’s Disease(AD) 50% • Vascular Dementia(VaD) 10% • Mixed Dementia-Alzheimer’s with cerebrovascular disease AD/VaD 25% • Dementia with Lewy Bodies(DLB) 10% • Fronto Temporal Dementia (FTD) 2%

  20. Alzheimer’s disease • Plaques, tangles • Insidious onset • Gradual decline • Memory orientation difficulties early on • Executive function impairment • Later on dyshasia, dyspraxia, agnosia

  21. Vascular Dementia • Pure form not that common • Single large infarct • Multi infarct dementia • Subcortical dementia RISK FACTORS • Male • Stroke/TIA

  22. Alzheimer’s with Cerebrovascular disease Gradual deterioration • RISK FACTORS • Family history dementia • Increasing age • Atrial fibrillation • Hypertension • Hypercholesterolaemia • Diabetes • Homocysteine • ?Lack of Exercise

  23. Modifying Risk • NB long latency(10+ years) between modifying risk factor and seeing effect on disease • ANTIOXIDANTS • Vitamins C & E in combination • ?Vitamin E delaying institutionalisation • ANTIANFLAMMATORIES • Non steroidal antiinflammatory agents ?Some benefit if taken over many years

  24. Modifying Risk • Tobacco- risk not reduced-stimulation of nicotinic receptors offset by other deleterious effects • Alcohol- mild drinking up to 3 units of wine per day benefit • Statins- beneficial in TIAs, stroke, hypercholesterolaemia, dementia-mixed results. May increase alpha secretase • B12 & folate long term to reduce homocysteine? • Oestrogen? • Increased exercise? • Mental stimulation?

  25. Modifying Risk • Fish 3x/week • Curry-turmeric • Smart drugs? • Bandolier’s 10 Tips

  26. Dementia and Parkinson’s Disease(PD) • PD and subcortical dementia • PD and AD • PD and hallucinations from treatment • Dementia with Lewy Bodies(DLB)

  27. Dementia with Lewy Bodies • Fluctuating course • Visual hallucinations • Spontaneous features of Parkinsonism

  28. Dementia with Lewy Bodies • Falls • Syncope • Systemised delusions • Hallucinations in other modalities • Neuroleptic sensitivity

  29. Fronto Temporal Dementia • 30% of younger onset dementia(45-65yrs) • Duration 8yrs • Overactive-disinhibted, lack of concern(orbitomedial frontal, anterior temporal) • Apathetic-perseveration, rigid thinking, lack of volition(pan frontal) • Stereotyped ritualistic behaviour(striatum) • Semantic dementia-unable to understand meaning of words, objects, sensations • Progressive non fluent dyshasia

  30. Fronto Temporal Dementia • Liking for sweet things • Emotional blunting • Striking loss of insight • Ability may be enhanced-artistic or musical • Tip-frontal lobe symptoms often precede memory problems

  31. Other Dementias • Subdural haematoma-history of fall • Creutzfeld-Jacob Disease-Classical-rapid decline, myoclonus, abnormal EEG, death in < 1 yr • Normal pressure hydrocephalus- cognitive change, gait abnormality, urinary incontinence

  32. The Dementias: Identify and Diagnose • History • Cognitive testing • Primary Care 6CITMMSE • Physical examination

  33. The Dementias: Dementia Screen • FBC ESR • U&Es • LFT’s, Calcium, protein • Blood Sugar • Lipids • B12&folate • TFTs • Serological Tests for syphilis • ECG

  34. Referral to Old Age Psychiatry • Early for diagnosis, comprehensive assesment

  35. Treatment With A Cholinesterase Inhibitor (CHEI) • Mild to moderate AD, Mixed AD/VaD, DLB • Secondary Care • Shared Care Protocol

  36. Dementias:Treatment • Memory clinic • History • Examination • Investigation • Diagnosis • Treatment

  37. Memory Clinic • Patient and carer(s) • Detailed assessment and review • Mini Mental State Examination • Clock Drawing Test • Demtect • Executive Function • Bristol Activities of Daily Living • Peripatetic

  38. NICE Guidelines(2001) • Mild to moderate Alzheimer’s Disease • >12 MMSE • Diagnosis in specialist clinic • Treatment initiated by specialist but may be continued by primary care under shared care protocol • Seek carers’ views • Assess 2-4/12 after maintenance dose. Continue only if improvement in MMSE score or no deterioration and behavioural or functional improvement • Review every 6/12- MMSE must remain >12 and worthwhile effect on global functional and behavioural condition

  39. Goals of Treatment • Enhance Cognition • Increase autonomy • Decrease behavioural symptoms • Slow or arrest progression of the disease • Primary prevention in the presymptomatic stage

  40. Memory Clinic- Indications for CHEIs • Dementia screen • ECG • Neuropsychological testing-if MMSE>19 • CT Brain scan with medial temporal lobe views • One hit

  41. Memory Clinic • If AD, mixed dementia or DLB • MMSE >12 • Compliance with medication • Regular observation of patient • No contraindications

  42. Memory Clinic • Prescribe CHEI • Patient and carer information • Support or care at home • Monitoring and treatment of BPSD • Review 3/12 after stabilisation

  43. Memory Clinic • Review • Usually every 6/12 • MMSE, CDT, EF, BADL? • Continue if evidence of benefit- not so easy to decide!

  44. Memory Clinic • Stopping CHEIs • MMSE <12 • Marked deterioration • Withdraw over 2/52 • Often severe relapse- need to restart within 4/52

  45. The Dementias:CHEIs • Side effects-cholinergic-nausea, headache,sweating, bradycardia dizziness • Cautions-asthma, sick sinus syndrome • Outcome-actual improvement in behaviour cognition, function, psychosis • Slowing of deterioration • Up to 18/12 • Stopping

  46. The Dementias: Treatment Memantine • Licensed for moderate to severe dementia • Not supported by Priorities Committee in W Berks • Modest evidence of benefit in cognition, ADL, behaviour

  47. Other Treatments • NSAIDs-Low rates of AD in patients with RA. Insufficient evidence • HRT- no effect in established disease, possibly preventative

  48. Other Treatments: Antioxidants • Vitamin E ? Delays institutionalisation. Dose 1000 IU/day Gingko Biloba- some benefit reported from German studies • May interact with anticoagulants

  49. Possible FutureTreatments • Prevent plaque formation • Vaccination –Beta amyloid • Nerve growth factor • Stem cells

  50. The Dementias: Other Pharmacological Treatments • Agitation, irritability, anxiety and verbal aggression • Trazodone 50mgs/day up to 250mgs day • Sedation, anticholinergic • Citalopram 10-20mgs/day up to 40mgs/day • palpitations., postural hypotension, confusion • Depression- antidepressant

More Related