Delirium Basics
Screening tool used for diagnosis of delirium?
Confusion Assessment Method.
Characterized by Gait dysfunction, Urinary incontinence & Cognitive impairment.
Normal pressure hydrocephalus (NPH)
Chromosomal disorder commonly associated with development of early-onset Alzheimer disease
Down syndrome (trisomy 21)
(It results from an extra copy of chromosome 21, where the APP gene is located; the extra copy of APP is thought to accelerate amyloid beta accumulation leading to early-onset AD)
Pharmacologic options for mngt of Alzheimer disease (name 3)
Donepezil, rivastigmine, galantamine, Memantine.
NB: antiamyloid therapies aducanumab and lecanemab received FDA approval for treating patients with symptomatic Alzheimer disease, although aducanumab is no longer being produced.
+ve: first two points and either point 3 or point 4 present
Characterized by early personality changes, disinhibition, apathy, loss of empathy, hyperorality, and compulsive behaviors.
Frontotemporal dementia (FTD)
Dementia syndrome where motor symptoms precede the cognitive impairment by at least 2 years.
Parkinson disease dementia
First-line pharmacologic treatment for REM sleep behavior disorder (RBD) in Dementia with Lewy bodies?
Melatonin (high-dose, 5–12 mg at bedtime).
[Second-line if persistent = clonazepam]
Common Triggers for Delirium (List five)
Infections, Alcohol, Medications, Fluid and electrolyte abnormalities, Uncontrolled pain, Hypoxemia, Anemia, Visual and hearing impairment, Prolonged hospitalization, sleep cycle disruption
Dementia and motor symptoms developing within 1 to 2 years of each other, associated with recurrent well-formed visual hallucinations.
Dementia with Lewy bodies
(Chacterized by fluctuating cognition, recurrent well-formed visual hallucinations, parkinsonism (occurring within 1 year of dementia onset), and REM sleep behavior disorder.
First and most prominent feature in NPH and also the most likely to respond to shunting.
Gait disturbance
[high-volume LP (30–50 mL CSF removed) — objective gait improvement within 1 hour = high positive predictive value (>90%)]
Definitive treatment for NPH
Ventriculoperitoneal (VP) shunt — diverts CSF to the peritoneal cavity.
Last resort in delirium mngt and only used when behavioral or all other medical measures fail.
Physical restraints
Classically shows a stepwise progression of cognitive decline, executive dysfunction more prominent than memory loss, focal neurologic signs, and neuroimaging evidence of infarcts or white matter changes.
Vascular dementia
Two hallmark microscopic pathologic features of Alzheimer disease
(1) Neuritic (senile) plaques — extracellular deposits of amyloid beta; Congo red–positive and birefringent; found in hippocampus and cerebral cortex.
(2) Neurofibrillary tangles (NFTs) — intracellular inclusions of hyperphosphorylated tau protein
Drug class that reduces compulsive and disinhibited behaviors in frontotemporal dementia
SSRIs (eg, sertraline, fluoxetine)
[do not improve cognitive function while AChEIs and NMDAIs-have little to no proven benefit]
Antipsychotic meds (eg, olanzapine, quetiapine) are reserved for severe agitation
Medication generally avoided in delirious elderly patients because of paradoxical disinhibition?
Name one important exception.
Benzodiazepines
Exception: delirium caused by alcohol withdrawal
Characterized by a progressive decline in memory, cognitive function (eg, executive function, visuospatial ability, language), and behavior.
Alzheimer disease (AD)
Genetic mutation(s) linked to early-onset Alzheimer disease
-Amyloid-precursor protein (APP), presenilin-1 (PSEN1), and presenilin-2 (PSEN2).
[Late-onset AD (age >65) is associated with the apolipoprotein E (APOE) gene]
Treatment option for patients with advanced Parkinson disease refractory to pharmacotherapy or experience refractory tremor, levodopa-induced dyskinesia, and/or motor fluctuations.
High frequency Deep brain stimulation
[most to least potent meds: levodopa+carbidopa, DAs: pramipexole, ropinirole, and MAO B inhibitors:selegiline, Amantadine].