questions 2

Delirium vs. Dementia

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Topic updated on 03/25/16 6:23pm

Snapshot
  • A 68-year-old patient presents to your service brought in by EMS from his retirement home.  He was found non-responsive by his nurse which prompted him to be brought in.  When you examine the patient you find a fiesty, responsive elderly gentleman who is alert and oriented x2 (he thinks it is 1940).  When you revisit the patient the next day he is difficult to arouse and responds with only incoherent grunts and keeps trying to sleep.  Patient has no significant past medical history and is on oxybutinin, lorazepam PRN for anxiety at night, and aspirin 81 mg.  Of note patient's hearing aid was broken recently in a rough game of dominoes.
Delirium
  • Acute onset change of consciousness with waxing and waning 
    • ↓ attention span
    • ↓ level of arousal
  • Characterized by 
    • acute changes in mental status
    • disorganized thinking
    • hallucinations (often visual)
    • illusions
    • misperceptions
    • disturbance in sleep-wake cycle
    • cognitive dysfunction
    • abnormal EEG
  • Most common psychiatric illness on medical and surgical floors
    • may be caused by drugs with anticholinergic effects
    • other causes include CNS disease, infection, trauma, withdrawal, and substance abuse
    • often reversible
  • Common causes
    • infection
    • UTI
    • URI
    • medications
    • substance abuse
    • alcohol
    • drugs
    • urinary/fecal retention
  • Management
    • treat the underlying cause
    • supportive measures
      • fluids
      • VDRL/RPR
      • B12 levels
      • thiamine, niacin, folate levels
      • TSH
      • depression screen
Snapshot
  • A 76-year-old patient is brought into your office by his son.  The son claims that about 3 years ago his father had to move in with him since he was having trouble paying his bills and maintaining his house.  This past year he states that his father is now having trouble dressing himself, and sometimes wanders away and can't find his way home.  He can no longer bathe himself either which prompted the son to bring in the father.  On physical exam you find an elderly, unshaven gentleman who is alert and oriented x2 (not sure of the date).  The patient is able to answer some questions, but cannot remember where he lives, or why he is at the doctor currently.
Major Neurocognitive Disorder
  • Major neurocognitive disorder (DSM-V)
    • formerly dementia and amnestic disorders under the DSM-IV
    • can be subcategorized into major and minor neurocognitive disorder
      • difference in diagnosis is arbitrary, but allows for stratification of severity of symptoms
  • Gradual loss in cognition
    • NO CHANGE in level of consciousness
    • memory loss is present
    • symptoms are NOT fluctuating in a rapid fashion
  • Characterized by
    • memory deficits
    • aphasia
    • apraxia
    • agnosia
    • loss of abstract thought
    • behavioral/personality changes
    • impaired judgment
    • no loss of alertness
    • ↑ incidence with age
    • normal EEG
  • Caused by
    • Alzheimer's disease
    • thrombosis/hemorrhage
      • can have acute onset / step-wise progression
    • HIV
    • Pick's disease (fronto-temporal dementia) MRI demonstrating frontotemporal degeneration in Pick's disease
    • Lewy-bodies (Parkinson's dementia) Lewy Body dementia - Lewy bodies
    • substance abuse (neurotoxicity)
    • CJD CJD - Spongiform change
  • Diagnostic tests
    • B12, thiamine, folate, niacin levels
    • VDRL/RPR
    • TSH
    • screen for depression
    • rule out metabolic cause (CMP)
  • Depression may present as dementia in elderly patients
    • known as pseudodementia


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Qbank (1 Questions)

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(M1.PY.28) A 78-year-old male has been hospitalized for the past 3 days after undergoing a revision left total hip replacement. Over the past several hours, the nursing staff reports that the patient has exhibited fluctuating periods of intermittent drowsiness and confusion where he has been speaking to nonexistent visitors in his hospital room. The patient's daughter is present at bedside and reports that the patient lives alone and successfully manages his own affairs without assistance. Which of the following is most likely true of this patient's current condition? Topic Review Topic

1. Anticholinergic medications may alleviate his symptoms
2. Beta-amyloid plaques and neurofibrillary tangles are pathologic findings associated with this condition
3. Short-term memory is often impaired, with sparing of remote memory
4. The condition is typically irreversible, representing a common complication of aging
5. Possible etiologies include infection, trauma, or polypharmacy

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