Delirium or Dementia?

advertisement
Delirium or Dementia?
Dave Garbera
F1 Doctor
Arrowe Park Hospital
Learning Objectives
 What is the difference between delirium and dementia?
 Common causes of an acute confusional state
 Types of dementia
 Case study
Confused Patients
Delirium
Dementia
Psychiatric
Third Year
“A temporary mental state with a sudden onset, usually reversible,
including symptoms of poor attention, inability to concentrate,
Delirium
disorientation, anxiety and sometimes hallucinations
”
 Also known as Acute Confusional State
 Arises during a number of different acute illnesses
 Present in up to 20% of hospital admissions
 A lcohol
 D rugs
 E lectrolytes
 L iver failure
 I nfection
 R etention
 I ntracranial pressure
 U rea
 M etabolic disease
Delirium
Causes
Drugs
Drugs
 There are LOTS of drugs that are known to precipitate confusion
 Alcohol
 Benzodiazepines (e.g. Diazepam, Lorazepam)
 Opiates (e.g. Morphine, Codeine)
 Tricyclics (e.g Amitryptiline)
 Digoxin
 Lithium
Electrolyte Disturbance
 Any electrolyte imbalance can cause confusion
 Abnormal values cause cells in the brain to swell
 Osmosis because cells contain lots of potassium
 Hyponatraemia
 Vomiting and diarrhoea
 Build up of fluid in the body (e.g heart failure)
 Hypercalcaemia
 Malignancy
 Hyperparathyroidism
Liver Disease
 Cirrhosis
 Alcohol
 Hepatitis
 Drugs
 Carcinoma
 Primary hepatoma
 Carcinoma
 Vascular
 Ischaemia
 Infection
 Hepatitis
 Epstein-Barr virus
 Metabolic
 Wilson’s disease
Liver Disease
 Anything that leads to hepatic failure prevents toxic
blood metabolites from being processed in the liver
 Metabolites then remain in the blood and cause
disturbance in the brain
Infection
 Number of acute infections can cause delirium
 Mechanism unknown, but probably due to inflammatory
response disrupting neurotransmitters
 UTI
 Pneumonia
 Sepsis
 Meningitis and encephalitis
 Malaria
Retention
 One of the most common causes of confusion in
hospital
 Both urinary and faecal
 Unknown aetiology
 Multiple studies
 Nobody knows why this should cause confusion
 Hypothesised that faeces become impacted due to
constipation, which presses on bladder
Intracranial Pressure
 Brain metastases
 Space occupying lesions
 Increase pressure in cranium
 Damage to brain tissue
 Increased volume in brain
 Oedema
 Hydrocephalus
 Trauma
 Space occupying haematoma
 Direct damage to brain tissue
Urea
 Often arises from renal failure
 Chronic kidney disease
 Acute renal failure
 Nephrotoxic drugs
 Urea and other waste products normally excreted by
the kidneys remain in the blood
 Acute confusional state caused by build up of toxins in
the brain, disrupting neurotransmission
Metabolic Disease
 Vitamin deficiency
 Especially B1 and B12
 Involved in nerve conduction
 Hypoxia (respiratory disease)
 Lack of oxygen
 Brain is not well perfused
 Thyroid disease
 Levels of thyroxine linked to precipitating confusion
Presentation
 Acute onset
 Agitation
 Fluctuating course
 Sleep cycle disturbed
 Impaired
 Hallucinations
consciousness
 Impaired cognition
 Disorientation
 Poor attention
History
 Usual medical history
 Any recent illness?
 Good medication history
 Obtain a collateral history from relatives or friends
 The patient will probably not be very cooperative!
Examination
 ABC
 Conscious level
 Vitals
 O2 Sats
 BP
 Pulse
 Temperature
 ENT, respiratory, cardiovascular, abdominal exams
 Check for lymphadenopathy and constipation
 Mini mental state exam
Investigations
 Blood glucose
 ABC-DEFG
 Bloods







FBC
U&E
LFT
TFT
Vitamin B12
Calcium
Cardiac enzymes
 ABG
 Urine dipstick
 Blood cultures
 ECG
 Chest / abdo x-ray
 CT Brain
 (Lumbar puncture)
Management
 Treat underlying cause
 Constipation – laxatives
 Urinary retention – catheterise
 Infection – antibiotics
 Electrolytes – fluids, slow calcium production
 Stop drugs suspected of causing confusion
 Replace with others if possible
 Measure cognitive function regularly
 Mini mental state examination
Management
 Supportive
 Clock, calendar in room
 Familiar objects from home
 Staff consistency
 Involve family and carers
 Helpful in stopping patients wandering
 Medical treatment
 Antipsychotic medication - haloperidol
 Haloperidol is for scared patients
 Other antipsychotics for other hallucinations or delusions e.g
quetiapine
Delirium
 Acute illness
 Sudden onset
 Altered consciousness
 Hallucinations
 Fluctuating disorientation and memory loss
 Thorough history and examination
 Treat underlying cause and stop precipitating drugs
 DRUGS
CONSTIPATION
INFECTION
“A progressive decline in cognitive function due to damage or disease
in the brain beyond what might be expected from normal aging”
Dementia
Alzheimer’s Disease
Vascular Dementia
Lewy Body Dementia
Fronto-temporal Dementia
Alzheimer’s Disease
 Most common type of dementia
 Accounts for up to 60% of all cases
 More common in women
 Risk increases with age
 Approx. 25-33% of 85 year olds in the West
 Some evidence of hereditary link
 Up to 10% more likely to develop Alzheimer’s if a first
degree relative has it
Key Features
 Memory impairment
 Ability to learn new information
 Recall previously learned facts
 Cognitive disturbances




Agnosia – inability to recognise people or objects
Apraxia – difficulty with sequencing
Language disturbance
Higher functioning such as planning
Key Features
 Personality well preserved
 No fluctuation in symptoms
 STEADY decline
 No problems with loss of consciousness
 No hallucinations or behavioural problems until very
late in the illness
 Sleep-wake cycle often reversed
 Eventually loss of central functions e.g continence
Alzheimer’s Disease Course
Severity
• Gradual decline over many years
Time
Pathology
 Due to deposition of abnormal proteins throughout the
brain
 Beta-amyloid plaques
 These cause destruction of neurones and therefore
cognitive decline
 Neurofibrillary tangles
 Deposits of protein known as Tau which become ‘tangled’
causing neurone loss
Vascular Dementia
 Associated with other vascular problems
 Ischaemic Heart Disease
 TIA or stroke
 Smoking
 Similar features to Alzheimer’s
 Characteristic ‘stepwise’ pattern of decline
Vascular Dementia Course
• ‘Stepwise’ decline
Vascular event
Severity
• Abrupt decline in
cognition with
each event
Time
Dementia with Lewy Bodies
 Very similar in pathology to Alzheimer’s
 Additional protein deposits in the brain stem known as
Lewy Bodies
 Similar course
 Additional features of:
 Parkinsonism
 Hallucinations from the outset (usually disturbing)
Fronto-temporal Dementia
 Also known as Pick’s Disease
 Tau deposition similar to Alzheimer’s
 General cognitive decline
 Additional features of:
 Personality change
 Disinhibition
 Inappropriate actions
History
 Very important – has the decline been sudden or
steady?
 Like delirium, it is important to take a collateral history
from a friend or relative
 The patient will probably be unable to tell you accurately
themselves
 Rule out all causes of delirium before diagnosing
dementia
 Acute illness? Medication? Constipation?
Investigations
 Diagnosis is usually clinical and based on the history
given by friends, family or carers
 Mini mental state examination
 A score of 23 or less indicates probable dementia
 Standard battery of investigations for delirium
 CT Brain if unsure
 Generalised cerebral atrophy
 Enlargement of ventricles
Treatment
 Very few treatment options
 No cure
 Most promising currently are anti-acetylcholinesterase inhibitors
 Donepezil
 Rivastigmine
 Theory that lack of neurones, and therefore acetylcholine, slows
cognition
 These drugs prevent reuptake of acetylcholine in the synapse,
therefore maximizing cognitive function
 Unclear as to how much these drugs slow decline
Alzheimer’s Disease Course
Severity
• Gradual decline over many years
Time
Support
 Support for patient, family and carers is very important
 Visits from specialist nurse
 Incontinence control
 Counselling
 Keep family informed as to what the course of the
illness will be and what to expect
 There is no effective treatment
Delirium or Dementia?
Delirium
Dementia
Onset
Sudden
Gradual
Duration
Acute
Chronic
Cause
Acute illness
Brain disorder
Course
Often reversible
Progressive
Disorientation
Early
Late
Stability
Variable
Mostly stable
Consciousness
Altered early
Very late
Attention Span
Often reduced
Slightly reduced
Hallucinations
Common
Uncommon
Memory
Variable
Lost
Need for treatment
Urgent
Desirable
Case Study
 75 year old male presents with marked memory loss,
difficulty recognising family. No loss of consciousness
or hallucinations. His daughter lives in New Zealand
and is able to visit once a year.
 He complains of burning pain on urination for four days
 PMH
 Lung cancer
 Liver metastases
 CKD Stage IV
Medication and Family History
 Atenolol
 Digoxin
 Simvastatin
 Aspirin
 Omeprazole
 Father had Alzheimer’s disease
Examination
 Temperature 38.2ºC
 Pulse 100
 BP 130/80
 Respiratory rate 14
 O2 Sats 99% on room air
 Mini mental state exam - 23
 Chest clear
Differential Diagnosis?
 Delirium
 Possible UTI
 Several risk factors in PMH
 Medication
 Fever
 Dementia
 Family history
 Sustained inability to recognise people
 No hallucinations
 Mental state not fluctuating
Investigations
 Blood glucose 6.5
 Arterial Blood Gases
 PaO2 14kPa
 PaCO2 5kPa
 Bloods








Hb 130
WCC 24
CRP 150
LFT Normal
TFT Normal
U&E Normal
Calcium normal
Digoxin level normal
 Blood cultures
 No significant growth
 ECG
 Sinus rhythm
 No abnormality
Investigations
 Urine dipstick
 Nitrates +++
 Leukocytes +++
 Blood +
 Microscopy confirms E.Coli
Diagnosis?
 Delirium secondary to urinary tract infection
 5 day course of ciprofloxacin to treat
 Patient returns four weeks later with daughter
 She says he is still confused
 Burning sensation has disappeared
What next?
 CT Brain
Diagnosis?
 Alzheimer’s disease
 Many elderly patients will have multiple risk factors for
developing an acute confusional state
 Start on anti-acetylcholinesterase inhibitor
 Donepezil
 Advice and support to family
Remember
 Make sure you rule out all other causes before jumping
to conclusions
 Not all elderly people presenting with confusion will
have dementia
 Not everyone presenting with UTI and confusion will be
delirious
Any Questions?
Thank you!
Download
Related flashcards

Transfusion medicine

23 cards

Myeloid neoplasia

12 cards

Blood donation

15 cards

Hematology

56 cards

Create Flashcards