week 7: neurocognitive disorders

Core characteristics of delirium:

1

2

3

4

Change in attention

Change in condition

Abrupt onset

Fluctuating course

Common causes of delirium: (9)

Infection

Fluid/electrolyte imbalance

Hepatic or renal failure

Head trauma

Post-anesthesia

Seizure

Hypoxia

Medication-induced (Ex: sedative/hypnotic, anticholinergic, antihistamine)

Substance intoxication or withdrawal

Risk factors for delirium: (8)

Preexisting cognitive impairment

Older age

Cerebral damage

Illness

Some medications

Functional impairment

Hospital stays (esp in ICU & post-op care setting)

Being a resident in a nursing home

Symptoms of delirium: (7)

Altered LOC

Decreased awareness of environment

Attention problems

Recent memory impairment

Disorientation to time and place

Language disturbance

Perceptual disturbances (illusions, hallucinations)

Delirium workup subjective:

1

2

3

HPI

Med reconciliation

Collateral contracts

Delirium workup objective:

1

2

3

4

5

VS

Labs (CBS, UDS, UA, urine/blood C&S, LP, HIV, RPR)

Imaging (chest x-ray, head CT, MRI)

Physical assessment

MSE

Dementia progression- MILD:

1

2

Intermittent memory loss & confusion

Difficulty with problem solving

Dementia progression- MODERATE:

1

2

3

4

Increased cognitive impairment

Sleep disturbances

Apathy

Mood swings

Dementia progression- SEVERE:

1

2

3

4

Inability to maintain ADLs

Wandering

Paranoia

Pronounced communication difficulties

Risk factors for Dementia- Non-modifiable:

1. ___________

2 ___________ sex: higher risk of developing dementia compared to ____________

3 ___________ Gene- genetic predisposition a/w alzheimer's disease

4 ____________ injury

5____________ hx

6____________

age, female, men, ApoE e, Prior head, Family, Ethnicity

Risk factors for Dementia- modifiable:

1 ___________: prevent or manage through lifestyle changes

2 ___________: can be managed w/ diet & meds

3 ___________: can be managed through diet & meds

4__________: effective management can reduce risk

5 Social isolation, mental & physical inactivity

6 ___________

Stroke, Hypertension, Hyperlipidemia, Diabetes, Smoking

Dementia workup- assessment:

1

2

3

Interview the pt

Interview the caregiver

Functional status (ADLs & IADLs)

Dementia workup- objective:

1

2

3

4

5

1 Blood work

2 Urine C&S

3 EEG

4 Imaging

5 Neuropsychological exam

Psychiatric symp a/w dementia:

1

2

3

4

5

6

7

8

Mood changes

Sleep disturbance

Apathy (lack of interest/motivation)

Paranoia

Aggression

Social withdrawal

Disinhibition

Hypersexuality

Common causes of delirium in children:

Infections and sepsis

Febrile states

Neoplasm/cancer

Chemotherapy

Mental retardation

Closed head injury

Seizures

Hypoxia

Trauma

HIV/AIDS

Emergence from anesthesia

Use of anticholinergic agents

Environmental toxins, such as paint

Common causes of delirium in adolescents:

Trauma, such as head injury

Seizures from withdrawal

Overdose

Neoplasm

Autoimmune disorders

Environmental toxins, such as paint

Common causes of delirium in older adults:

Infections (resp/urinary)

Drug toxicity

Age > 65

Fluid & electrolyte imbalance

Hypoxemia due to medical conditions

Drug withdrawal (sedative/alcohol)

Urinary retention

Intracranial events (stroke/bleeding)

Acute myocardial/pulmonary events

Use of anticholinergic meds

Environmental toxins, such as paint

Safety consideration for neurocognitive disorders (9):

Falls

Elopement/wandering

Malnutrition

Swallowing difficulty

Med management

Financial abuse

Physical abuse

Neglect

Electrical/gas safety

delirium or dementia?

onset: abrupt, hours-days

delirium

delirium or dementia?

onset: insidious, month-years

dementia

delirium or dementia?

time course: acute; response to tx

delirium

delirium or dementia?

time course: chronic: progressive, deterioration w/ over time

dementia

delirium or dementia?

orientation: impaired initially

delirium

delirium or dementia?

orientation: usually preserved; may be impaired in advanced stages

dementia

delirium or dementia?

ADL: may be intact or impaired

delirium

delirium or dementia?

ADL: may be intact early, but impaired as disease progresses

dementia

delirium or dementia?

Attention: decreased

delirium

delirium or dementia?

Attention: normal except in severe stage

dementia

delirium or dementia?

reversibility: usually

delirium

delirium or dementia?

reversibility: irreversible

dementia

General approach to pharmacologic-management— delirium

1 Avoid meds that may worsen symp → ex: ___________

2 Consider ____________

3 ___________→ ex: antibiotics for infection

4 ___________→ lowest dose & shortest duration possible, avoid chem restraints

benzodiazepines, removing meds that can contribute to symp, Med to tx underlying causes as indicated, Least-restrictive

General approach to pharmacologic management— dementia:

1. ___________

2.___________: mild symp

3. ___________: mod-severe symp

4. ___________: mild symp

5. Med may be indicated for ____________→ ex: SSRI for depression

6. Black box warning for ___________ in dementia

Disease specific, Cholinesterase inhibitors, NMDA receptor agonist, Immune therapy, psychiatric comorbidities , antipsychotics

General approach to pharmacologic management— delirium

Avoid meds that may worsen symp → ex: ______________

benzodiazepines