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22 Cards in this Set

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What is delirium
Delirium is a disturbance of consciousness and attention that usually develops over a short period of time. The confusion and memory impairment is not better accounted for by a preexisting dementia
What causes delirium
Most often it is the result of a general medical condition, but it may also be due to substance intoxication or withdrawal. Almost any medical condition can cause delirium, especially in the elderly, i.e. metabolic derangements, infections, head trauma, and so forth. Often delirium is multifactorial
While most substances of abuse can cause delirium with acute intoxication, which three are most likely to cause delirium related to withdrawal
Alcohol (delirium trements), benzodiazepines, and barbiturates
What factors predispose to delirium
Acute medical illness
Age—elderly and young children
Preexisting brain damage—dementia, cerebrovascular disease, tumor
History of delirium
None
How common is delirium
Very common. Roughly 15% to 20% of general hospital patients will have an episode of delirium. In patients over the age of 65, the prevalence can be as high as 30%
Clinically, what is the hallmark of delirium
Altered level of consciousness (especially attention and level of arousal). It typically develops over a period of hours to days and mental status alterations wax and wane during the day, with periods of lucidity
In addition to alterations in consciousness, what other features are often found in a patient with delirium
Altered sleep-wake cycle
Perceptual disturbance
Impaired memory and orientation
Nocturnal worsening of symptoms
Psychomotor agitation
None
How do you test for delirium
You cannot. There is no test that is definitive for delirium. EEG may show nonspecific changes such as diffuse slowing
How do you treat delirium
Treat the cause. The medical “workup” in delirium is really just a hunt for the cause. Tip: Think of delirium like a fever. The fever is not the primary problem; what ever is causing the fever is the problem
While identifying and treating the cause of a delirium, how do you manage a delirious patient
Orient the patient frequently and place him in a brightly lit room during the day. Low doses of antipsychotics, like haloperidol or risperidone can be helpful for agitation and hallucinations. Small doses of benzodiazepines can also help with agitation (use benzodiazepines sparingly as they can worsen confusion and/or disinhibit the patient)
What is the core symptom of dementia
Memory impairment
In order to diagnose dementia, what must be present in addition to memory impairment
At least one of the following:
Aphasia (language and naming problems)
Apraxia (impaired ability to do learned motor tasks, like using object)
Agnosia (difficulty recognizing or identifying objects)
Disturbance of executive function (the ability to plan, organize and carryout tasks, judgement)
None
How does dementia differ from the normal memory changes of aging
As we age, we are less able to learn new information, and we process information at a slower speed. However, these changes do not normally interfere with the basic functioning
When diagnosing dementia, what other disorders in your differential are key to rule out
It is crucial that you not miss a delirium or a depression. In the elderly, it is not uncommon for them to report multiple memory complaints. If you misdiagnose this as dementia, you will miss a potentially reversible cause of memory impairment. Likewise, if you miss a delirium, you may miss a potentially serious medical problem. Additionally, there are several potentially reversible causes of dementia that you should look for, including neurosyphilis, B12, thiamine and folate deficiencies, and normal pressure hydrocephalus
What is the prevalence of dementia
Incidence/prevalence increases with age. The prevalence is approximately 1.5% in those over 65 years of age. The prevalence increases to 20% after age 85
What is the most common type of dementia
Alzheimer’s represents about 50% to 60% of dementias. The second most common form is vascular dementia (formerly multi-infart dementia); Others include front temporal (Pick’s and Creutzfeldt-Jakob), Parkinson’s, Huntington’s, and HIV dementias
What is the classical clinical course for Alzheimer’s disease
Slow, gradual onset of memory loss and cognitive impairment (often there are problems with judgement, mood symptoms, and behavioral disturbances as well). The disease is progressive and death usually occurs within 3 years after diagnosis
How does the course of Alzheimer dementia differ from the course of vascular dementia
Vascular dementia classically has a stepwise decline, as opposed to the slow and steady decline in Alzheimer’s. Onset of deficits may be abrupt, and with good control of cardiovascular risk factors the course may remain relatively stable
What are the major risk factors for Alzheimer’s
Age, family history, Apo E4 allele, and Down syndrome
On postmortem exam, what changes are normally seen in the brain of an Alzheimer’s patient
Neurofibrillary tangles and senile (amyloid) plaques
What areas of the brain show cell loss in Alzheimer’s
While there is also often global cortical atrophy, neuronal degeneration is classically in the cholinergic neurons of the nucleus basalis of Meynert
What class of medications is used to slow the progression of Alzheimer’s
Acetylcholinesterase inhibitors. Since the cholinergic cells are being lost, these medications help increase the presence of acetylcholine in the brain by inhibiting the breakdown of this neurotransmitter