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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.

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Delirium

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  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

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