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Flashcards in Reisert: Dementia and Delerium Deck (73)
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acute confusional state with decreased attention that usually lasts over hours to days, but may last months to years

Delirium

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Also known as:

  • confusion
  •  encephalopathy
  • acute brain failure
  • acute confusional state

Delirium

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  • Older age, baseline dysfunction (failing health, dementia, nursing home patients)
  • poor sleep
  • hospitalization (Catheters, restraints, sleep deprivation, multiple meds, pain)

Epidemiology of Delirium

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Decreased attention is KEY

May have additional sx:

  • change in sleep awake cycles
  • hallucinations
  • delusions
  • ANS changes such as HR or BP problems
  • hypo or hyperactive status

PE features of Delirium

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  • Usually due to diffuse cerebral dysfunction
  • May be r/t low Ach levels
  • May mimic Alzheimer's, Lewy body dementia
  • High dopamine levels possible

Pathology of Delirium

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Clinical at bedside

Compare baseline function (ask family)

Check for medications: 

  • anti-cholinergics
  • sedatives/narcotics/benzodiazepines

 

Diagnosis of Delirium

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  • ICU/ Post-op psychosis
  • Sundowning
  • Delirium tremens

Delirium syndromes

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Illness:

sepsis, fever, dehydration, drug abuse

Causes of ICU/Post-op psychosis 

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Old people who get worse at night 

  • common
  • worse if underlying mental health issues, especially dementia 

Various degrees of delirium

 

Sundowning 

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Maintain day-awake cycle

Night-sleep normalcy

Reassurance/reorientation

Treatment of sundowning 

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Mild:

  • Tremor
  • Agitation, anxiety

DT's

  • Intense reaction

Sx of alcohol withdrawal

 

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Usually begins 5-10 hours after cessation

Peaks 2-3 days after cessation

Alcohol withdrawal 

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Alcohol withdrawal syndrome that is worse in context of illness (hospitalization)

Delirium tremens

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  • Agitation
  • Tremor
  • Hallucinations
  • ANS instability (increased BP, pulse, resp)
  • Seizures

Sx of Delirium tremens 

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treat as status epilepticus

Tx for seizures during Delirium tremens 

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Don't drink

Slow taper off EtOH

Safe enviro/reoreintation/family, B vitamins, hydrate, treat illnesses

Benzodiasepines

Phenobarbital (less proof?)

Prevention of delirium tremens 

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  • Benzo's
    • Longer acting better
      • Diazepam (Valium)
      • Chlordiazepoxide (Librium)
    • IV or PO
    • Bad DT's: high dose 
  • Phenobarbital
  • Antipsychotics
    • Haloperidol (Haldol)

Tx of delirium tremens 

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Infection

Sepsis

Drugs

Medications

Reversible causes of delirium 

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HIgh mortality and morbidity

23-33% die (same incidence as sepsis)

longer length of stay

Outcomes of delirium 

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  • Toxins 
  • Metabolic
    • liver, kidney, electrolytes, glucose
  • Infection 
  • Endocrine 
    • thyroid, Vit. B12 def.
  • Cerebrovascular
    • stroke, seizure/post-ictal, metastasis, HoTN
  • Vasculitis 

 

 

 

 

 

Delirium workup

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Labs (basics-case specific)

Imaging RARELY helpful

Lumbar puncture

EEG to r/o seizures

Delirium workup

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Case by case directed-very difficult 

Supportive (reorientation, safety)

Day/night normalcy

Home like enviro

 bed alarms/sitters

Antipsychotics (Haldol, new "Atypicals")

Benzo's (not as good-sedation)

Bedrails

 

Tx of delirium 

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>4M americans

>$100B annual cost

Dementia 

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"Benign forgetfulness of elderly"

May progress to mild cognitive impairment

Can later develop in some

Dementia

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Memory loss

 10% >70 y/o 

20-40% >85 y/o

Dementia

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Continuum of diease with KEY features

Memory loss (KEY)

Other problems that develop later:

Speech and language difficulties, problem solving difficulties, impaired judgement, mood issues

Often progresive

Dementia 

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Mood disturbances may or may not be seen

  • Depression
  • Agitation
  • Delusions
  • Insomnia
  • Disinhibition

Dementia 

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Changes in cerebral circuits

Nerve loss

Changes in neurotransmitters: Acetylcholine, serotonin, glutamine

 

Neurological features of dementia 

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Age: by far the greatest 

Viral: Creutzfeldt-Jakob

Genetics?: FH of presence of apolipoprotein ε4-a mutant apolipoprotein that may have implications in amyloid formation

Risk factors for dementia 

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  • Alzheimer's disease: 50% of dementias!
  • Vascular: 10-20%
  • Multi-infarct
  • Frontotemporal: Huntington's
  • Parkinson's
  • With Lewy bodies
  • ETOH/Drugs
  • Viral/prion disease (Creutzfeld-Jakob: fast progression)

Major types of Dementia 

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Depression

Hydrocephalus

ETOH

Dementia look-a-likes 

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Memory loss is often subtle

Progressive over years 

Alzheimer's dementia 

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Neuritic plaques ("senile plaques")

amyloid (Aβ amyloid, Aβ42 amyloid or simply “Beta amyloid”) deposition in arterial walls of neurons

neurofibrillary tangles in cytoplasm of neurons

Pathology of Alzheimer's dementia 

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Affects more women due to longevity

Affects all intellecutal levels, but higher incidence in Down's syndrome

Alzheimer's dementia 

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What must you rule out with ICU/Post-op psychosis?

Stroke!

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Difficulty with ADL's 

lack of recognition of disease (anosognosia)

Behavior changes-may get lost

Word finding issues/other speech difficulties

Can't do puzzles 

Dementia

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  • Wandering
  • Poor judgment 
  • Delusions
  • Agression
  • Sleep disruption, altered sleep-awake cycle
  • Incontinence
  • Bedridden
  • Death (infection, malnutrition, heart disease) in 8-10 years (up to 25)
  • Confirm on autopsy

 

Late sx of alzheimer's dementia 

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Family education

Respite care, adult daycare

Safety (wandering, falls, driving)

Medications 

Tx for Alzheimer's dementia 

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A type of vascular dementia

Classically in HTN patients

May progress different

Multi-infarct dementia 

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Larger area, more dementia

Presentation more sudden onset 

Looks like AD, may have amyloid, with increase risk of hemmorhage

Vacular dementias 

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Diffuse what matter disease (Binswanger's dx or leukoaraiosis)

Large or small infarcts, lacunar infarcts (HTN)

Vascular dementias 

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Treat risk factors

Medications less helpful

Tx of vascular dementias 

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Huntington's chorea

Pick's disease

Progressive supranuclear palsy 

Examples of frontotemporal dementias 

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Memory loss typically later in disease

Attention issues, judgment impairment, awareness, behavior problems

Aphasias seen

Males>females

 

Frontotemporal dementias 

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Autosomal dominant inheritance

Chromoome 4

Family history

50% chance of getting 

Huntington's chorea 

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Signs: writhing movements (chorea, dancing)

Sx: Motor and cognitive problems (emotional)

Signs/Sx of Huntington's chorea 

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Onet 35-45 years old

After childbearing

Fatal in about 20-25 years 

Course of Huntington's chorea 

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Involuntary movements that look like jerks/tics that they can't control

After 10 years --> movements are slow (Parkinsonoid like) with bradykinesias, rigidity, dystonia 

mood changes

cerebral atrophy

Huntington's chorea 

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Family history

Genetic test

Diagnosing Huntington's chorea 

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  • Symptom treatment: 
    • Dopamine blockers (tetrabenazine)
      • helps with chorea
    • Anti-psychotics
    • Anti-depressants
  • Genetic counseling?

Tx of Huntington's chorea 

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Anterior frontal and temporal cerebral cortex

Intracellular inclusions (Pick bodies) stain with silver stain 

Pick's disease

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No treatment 

Just treat behaviors 

Pick's disease 

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  • Parkinson's like
  • Falls
  • Gaze parakysis (can't look down)
  • Rigidity
  • Dementia
  • May development poor judgement, apasia

Treatment: not real helpful

Death 5-10 years

Progressive supranuclear palsy

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Classic features of Parkinson's with dementia:

Tremor

Rigidity

Masked facies

Bradykinesia

Cogwheeling

 

Signs/Sx of Parkinson's dementia 

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Do all patients with Parkinson's get Parkinson's dementia?

NO! 

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  • Visual hallucinations
  • Parkinson’s features
  • Decreased alertness
  • Presentation often delirium in face of infection or given L-dopa drug for Parkinson’s and get delirium
  • Episodic confusion that waxes and wanes, but persists
  • Lewy bodies are intraneuronal cytoplasmic inclusions that stain with PAS staining
  • May have cholinergic defect
  • May overlap with other dementias

Signs/Sx of dementia with Lewy bodies 

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Treatment for dementia with Lewy bodies?

Anti-cholinergic drugs 

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Gate ataxia

Dementia

Urinary incontinence 

Normal pressure hydrocephalus 

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Imaging shows large ventricles

Some use MRI for imaging

Some use supervised CSF tap

DIFFICULT diagnosis to make

Diagnostics for normal pressure hydrocephalus 

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Treatment for normal pressure hydrocephalus?

Shunting 

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  • Long term use
  • Vitamin deficiences: Wernicke's encephalopathy
    • Thiamin deficiency
    • Confusion, ataxia, diplopia due to opthalmoplegia 

Ethanol induced dementia 

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Treatment for Wernicke's encephalopathy/Thiamin deficiceny?

100mg IV thaimin x 3 days

 

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Can't recall recent memory despite immediate memory retention

Get easily confused

Confabulation

Korsakoff's syndrome 

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Often spinal cord issues (myelepathy)

Macrocytosis

Treatment: replace wtih sv Vit. B12

Vitamin B12 deficiency 

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Not a dementia

Awake and fine then later forget a moment of time 

SCARY patient 

Transient global amnesia 

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Etiology of transient global amnesia?

Somewhat unknown?

Migraine, stroke?

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Tx for transient global amnesia?

Reassurance!

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Perhaps the most important thing!

Wrong diagnosis --> wrong treatment 

Recognition and diagnosis of dementia 

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What are some histories seen with dementia?

  • memory loss, duration
  • Other sx (driving, shopping, eating, depression, erratic behavior, hallucinations, tremor/Parkinson's)
  • Strokes/CV risk factors (esp. multi-infarct dementia)
  • HIV.syphilis
  • head trauma (hydrocephalus)
  • Nutrition isses (ETOH/thiamin deficiency, gastric bypass/obesity surgeries)

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History

Mini-mental status exam

Full neuropsychiatric testing

Parkinson's features?

Atrial fibrillation, HTN, etc

Labs: B12,  Thyroid recommended by American Academy of Neurology

Exam/Work up for _____?

Dementia 

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Delay progression of disease

Improve caregiver fatigue

decrease agitation

Pharm therapy in dementia 

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CT or MRI

Looking for:

atrophy, hematoma, infarction, tumor

Imaging for dementia 

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It is also important to treat who in dementia?

Caregivers