canning division dementia or delirium or depression dr nick bretland canning division of general...
Post on 01-Apr-2015
233 Views
Preview:
TRANSCRIPT
Can
ning
Div
isio
n Dementia or Delirium or Depression
Dr Nick Bretland
Canning Division of General Practice
Can
ning
Div
isio
nWhat is Dementia?
• Sustained reduction of previously established mental abilities
• Involves several areas of cognition
• Clear consciousness
• Causes functional problems
Can
ning
Div
isio
nTypes of Dementia
• Alzheimer’s Dementia
• Vascular Dementia
• Frontal Lobe Dementia
• Lewy Body Dementia
Can
ning
Div
isio
nAlzheimer’s Dementia
• Slowly Progressive
• Earliest Loss is Recent Memory
• Often preceded by Depression
• Progressive decline in intellect
• Progressive loss of functional abilities
• Neurological losses
Can
ning
Div
isio
n
Can
ning
Div
isio
nVascular Dementia
• Multi-infarct (usually embolic)• Small vessel infarct (disconnects
frontal lobes)• Picks off individual executive
functions• Often combined with Alzheimer’s
Dementia• Neurological symptoms
Can
ning
Div
isio
nPeriventricular White Matter Loss
Can
ning
Div
isio
nFrontal Lobe Dementia
• Specific loss of Frontal Lobe tissue• Main losses
– Recent Memory– Language– Executive function– Personality change
• Behaviour• Depression• Hallucinations
– Neurological Symptoms
Can
ning
Div
isio
nFrontal Lobe Atrophy
Can
ning
Div
isio
nLewy Body Dementia
• Variable levels of cognitive loss from day to day
• Parkinsonian features– Tremor– Shuffling Gait– Instability
• Prominent hallucinations– Well formed– Often people– Not frightening
Can
ning
Div
isio
nSymptoms of Depression
• Depressed Mood• Loss of interest or pleasure• Significant appetite or weight loss or gain• Poor sleep or excess sleep• Psychomotor retardation or agitation• Fatigue or loss of energy• Feeling worthless or guilt• Poor thinking and concentration• Suicidal thoughts
Can
ning
Div
isio
nDelirium
Transient Global Disorder of Cognition
• Affects 20-40% hospital admissions• Occurs in 80% of terminal illness• Mortality 10-26%• Prolongs Hospital Stay by 7 days• 25-50% have underlying dementia
Can
ning
Div
isio
nDSM IV Criteria
• Disturbed Consciousness– Reduced clarity of awareness of environment
– Reduced ability to focus or shift attention
• Change in Cognition– Memory deficit
– Language or perceptual disturbance
• Development over a short period of time and fluctuates through the day
• History, Examination and Laboratory findings indicate direct physiological consequences of a medical condition
Can
ning
Div
isio
nSubtypes of Delirium
1. HyperactivePicking at bedclothesTapping fingers,Agitation
2. HypoactiveLying passive in bed ( O sign)
3. Mixed4. Prodromal
Can
ning
Div
isio
nCauses of Delirium
• INFECTION• Hypoxia• Hypoglycaemia• Hyperthermia• Drugs (esp
anticholinergics)• Withdrawal
(alcohol and sedatives)
• PAIN• Metabolic• Vitamin deficiency• Urinary retention• Constipation• Sensory
deprivation• Heart, liver, renal
failure
Can
ning
Div
isio
nOn the Ward
• Top risk factors– Pre-existing Cognitive Impairment– Severe Medical Illness– Age 70 or over– Visual Impairment– Depression– Abnormal Sodium levels– Indwewlling Catheter– Use of Physical Restraints– Medications: Pethidine, BZD, Alcohol
withdrawal
Can
ning
Div
isio
nWarning Signs!
• High Index of Suspicion• Sudden onset of abnormal behaviour is more likely
to be delirium than dementia• Hallucinations are more likely to be due to
delirium than psychiatric illness• Sleep/Wake Cycle Reversal• Beware the Hypoactive Patient• Multiple medicines• Indwelling Catheters• Avoid physical restraints• Treat it as a medical presentation
Can
ning
Div
isio
nPrevention
• Environmental– Lighting appropriate to time of day– Single Room– Quiet – Clock and Calender– Family and Carer involvement– Familiar objects in Room
• Clinical– Assist with Eating and drinking– Glasses and hearing aids– Avoid Constipation– Mobilise– Medication Review– Manage Pain– Promote sleep
Can
ning
Div
isio
nManagement
• Identify Cause– History– Examination– Investigations
• Rating Scales– Clock Face– CAM– Delirium Rating Scale
Can
ning
Div
isio
nClockface Test
Can
ning
Div
isio
nTreatment
• Non-Pharmacological– Same as delirium prevention– One on One nursing– Validation and reality orientation– Family members to assist– Same staff – Relaxation Strategies to help sleep– NO PHYSICAL RESTRAINTS
Can
ning
Div
isio
nTreatment
• Medical– Treat underlying cause
• Pharmacological– SEVERE BEHAVIOURAL DISTURBANCE
ONLY – Antipsychotic meds (Haloperidol)– Second Generation Antipsychotics (Zyprexa,
Risperidone etc)– Low dose– Titrate up and review regularly
Can
ning
Div
isio
nBest Practice
• On Admission: – Baseline cognitive function (MMSE or AMT)
• Repeat assessment – day 6 and week 6– High risk cases may need daily assessment– sudden change in behaviour or cognition
• If Delirium Suspected – (MMSE declines by 2 or more points)– Formal assessment with diagnostic tool– Refer to “delirium expert”
Can
ning
Div
isio
nIs It Delerium?Delerium Dementia Depression
Onset Acute Insidious Variable
Course Fluctuating Steadily Progressive
Diurnal Variation
Consciousness & Orientation
Clouded & disorientated
Clear until late stages
Generally unimpaired
Attention & Memory
Poor short term memory. Inattention
Poor short term memory. No Inattention
Memory intact Poor attention
Psychosis Common (fleeting ideas with simple content)
Less common Uncommon (complex ideas with congruent mood)
Can
ning
Div
isio
n
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/
9E46460CFDAFBA03CA25732B004C4331/$File/Prevention.pdf
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ageing-
delirium.htm~ageing-delirium05.htm
top related