Mcphs Syncope, Delirium, Dementia

Front 1

Transient loss of consciousness and postural tone due to inadequate cerebral blood flow and O2 delivery

Back 1

Syncope

Front 2

Syncope is most common in what three types of patient?

Back 2

More common in pts with heart dz, older men and young women

Front 3

2/2 excessive vagal tone or impaired reflex control of peripheral circulation

Back 3

Vasomotor syncope

Front 4

What are two types of vasomotor syncope?

Back 4

Enhanced vagal tone secondary to hypotension
-Syncope in carotid sinus hypersensitivity
-Post micturation syncope

Vasodepression
-Often initiated by stressful, painful or claustrophobic experience
-Often in young women

Front 5

Vasoconstritctive response is impaired
Common in elderly, diabetic, pt w/ hypovolemia
Pt s taking vasodilators, diuretics, beta blockers
Idiopathic orthostatic hypotension (elderly men)

Back 5

Orthostatic (postural) Syncope

Front 6

No prodrome leading to injury is common

2/2 mechanical problem
Aortic stenosis, pulm stenosis, hypertrophic obstructive cardiomyopathy, right –to-left shunting, LA myoma obstructing the mitral valve

2/2 automaticity problem
Sick sinus syndrome, AV block, tachyarrhythmia

Back 6

Cardiogenic syncope

Front 7

What is used to diagnose syncope, ie. what tests?

Back 7

EKG, Tilt Table Testing, Electrophysiology studies, exercise testing

Front 8

Used in pts with recurrent syncopal episodes, nondiagnostic ambulatory EKGs and negative autonomic testing

Check sinus node fct and AV conduction

Try to repeat induction of supraventricular or ventricular tachycardia

Back 8

Electrophysiology studies

Front 9

This is used in patients who experience syncope with exertion or stress.

Back 9

Exercise testing

Front 10

How do you TX Syncope?

Back 10

Avoid predisposing situations
Stay hydrated
Stand up slowly
Maybe some serotonin reuptake inhibitors

Front 11

Acute fluctuating disturbance of consciousness associated w/ change in cognition or the development of perceptual disturbances
2/2 underlying medical condition such as infection, coronary ischemia, hypoxemia or metabolic derangement
Present in 25% of pts

Back 11

Delirium

Front 12

This is associated with the following:

↑ in hospital and post d/c mortality
↑ length of stay
↑ probability of NH placement

Back 12

Delirium

Front 13

What are the symptoms of delirium?

Back 13

Acute agitation (‘sun downing’)
Anxiety and irritability
Perceptual disturbance (visual hallucinations)
Psychomotor restlessness w/ insomnia
Marked deficit of short-term memory
Retrograde amnesia (can’t recall past memories) and anterograde (can’t recall events since onset of delirium)
Hypoactivity
Cognitive slowing
Inattention

Front 14

All of these things are risk factors for what?
Cognitive slowing
Male
Severe illness, infection
Fever
Hip fracture
Hypotension
Respiratory d/o
Malnutrition
Polypharmacy
Use of psychoactive medications
Sensory impairment
Use of restraints
Use of IV lines, urinary catheters
Metabolic d/o
Depression
Intoxication or withdrawal

Back 14

Delirum

Front 15

What is extremely important in delirium assessment?

Back 15

Current meds
Newly added meds
Discontinued meds (withdrawal)

Front 16

How do you manage delirium?

Back 16

Correct underlying cause
Eliminate unnecessary meds
Avoid restraints
Haldol 0.5-1 mg qhs or bid or
Quetiapine 25mg qhs or bid
In emergency: Haldol 0.5 mg po or IM q 30 min prn agitation
Side effect: prolonged sedation

Front 17

If delirium doesn't clear up shortly after treating it, what should you consider?

Back 17

Dementia

Front 18

Acquired, persistent, progressive impairment in intellectual fct with compromise of memory and at least one other cognitive domain

Insidious onset over months to years

Dx requires significant decline in fct that is severe enough to interfere with work or social life

Often associated with depression in early dz

Back 18

Dementia

Front 19

What are the risk factors of Alzheimer's

Back 19

Older age
Fam Hx
Lower education level
Female gender

Front 20

What are the risk factors of vascular dementia?

Back 20

Older age
HTN
Tobacco
Afib
DM
Hyperlipidemia

Front 21

What are the less common, potentially reversible causes of dementia?

Back 21

Drug effect
Depression
Thyroid dz
Vitamin B12 deficiency
Subdural hematoma
HIV infection
Normal-pressure hydrocephalus

Front 22

Dementia is characterized by Memory impairment + at least one of these

Back 22

Language impairment (initially word finding difficulty leading to difficulty following conversation leading to mutism)

Apraxia ( inability to perform previously learned task e.g. cutting loaf of bread, in spite of intact motor fct)

Agnosia ( inability to recognize objects)

Impaired executive fct ( poor abstraction, mental flexibility, planning and judgment)

Front 23

Problems w/ memory & visiospacial abilities (becoming lost in familiar surroundings, inability to copy geometric design on paper)

Social ability intact

Personality changes & behavioral difficulties (wandering, inappropriate sexual behavior, agitation)

Hallucinations (in moderate to sever dz)

End stage: near mutism, inability to sit up, hold up the head, track objects with eyes, difficulty with eating and swallowing, weight loss, bowel and bladder incontinence, recurrent urinary and respiratory infections

Back 23

Alzheimer's Disease

Front 24

Fluctuating cognitive impairment (thus can be confused with delirium)
Rigidity
Bradykinesia
Rare tremor
Poor response to dopaminergic agonists
Early Sx: Hallucinations (of people or animals)

Back 24

Lewy Body Dementia

Front 25

(group of dzs such as Pick’s dz. and others)
Personality change (euphoria, disinhibition, apathy)
Compulsive behavior (peculiar eating habits or hyperorality)

Back 25

Fronto-temporal Dementias

Front 26

This imaging in dementia is for younger pts w/ acute onset of focal neurologic symptoms, sz, gait abnormalities

Back 26

MRI

Front 27

This imaging in dementia is for older pts w/ classic presentation of Alzheimer’s

Back 27

Non-Contrast CT

Front 28

You use this to distinguish depression from dementia
In pts w/ very poor education or very high premorbid intellect
In pts with very mild impairment

Back 28

Neuropsych evaluation

Front 29

Plaques - deposits of the protein beta-amyloid accumulate between neurons

Tangles - deposits of the protein tau that accumulate inside of nerve cells

Back 29

Alzheimer's

Front 30

Plaques and tangles
Neuronal loss especially in subtantia nigra

Back 30

Lewy Body Dementia

Front 31

How do you TX mild to moderate dementia?

Back 31

Mild to moderate dz: Acetylcholinesterase inhibitor (donezepil, galantamine, rivastagmine)
Modest improvement in cognitive fct, but no difference in NH placement
Side effects: diarrhea, nausea, anorexia and weight loss

Front 32

How do you TX severe dementia?

Back 32

Severe dz: N-methyl-D-aspartate antagonist (memandine) +/- Acetylcholinesterase inhibitor
Unknown long-term benefit

Front 33

It is important to rule out what with dementia?

Back 33

R/o delirium 2/2 pain, urinary obstruction or fecal impaction