the confused elderly patient
DESCRIPTION
The Confused Elderly Patient. Dr C Kotzé Dept of Psychiatry 2012. Types of confusion. Chronic Dementia Disturbance of brain anatomy Long term (years) Primary or secondary cause. Acute Delirium Disturbance of brain physiology Short term (weeks) Secondary cause “Acute brain failure”. - PowerPoint PPT PresentationTRANSCRIPT
• Acute– Delirium– Disturbance of
brain physiology– Short term (weeks)– Secondary cause– “Acute brain
failure”
• Chronic– Dementia– Disturbance of
brain anatomy– Long term
(years)– Primary or
secondary cause
Types of confusion
Delirium
• Delirium is a medical emergency • Threatens the lives of older people
if not recognized and treated • It is a sudden change in mental
state• Fluctuates over 24 hours• Alters consciousness• Disturbs thinking and attention • Results in changed behavior
Delirium
Acute onset of clouding of consciousness
Attention deficit & forgetful Disorientation Perceptual disturbances Hypersensitive to light / sounds Sleep-rhythm disturbance Incoherent speech Changing psychomotor activity Fluctuation of picture
Characteristics
Infection (chest &UTI) Heart failure Metabolic disturbance Cerebro-vascular disease Drug administration Drug withdrawal (alcohol, BZ Hypothermia Any severe illness
Causes
Medical emergency Make an accurate diagnosis Treat any underlying
condition Stop offending drugs Avoid sedation unless
absolutely required Familiar medical personnel
should deal with the patient
Management
Aid orientation: get patient up spectacles & hearing aids provide clues to environment (signs etc)
Prohibit the use of cot sides Nurse the person low to floor Use a soft night-light
Management
Haloperidol 0,5mg bd
If severe restlessness: Lorazepam 2-4mg IMI q6h
In substance withdrawal delirium: Withdrawal regime of long acting BZ
Pharmacological
Dementia
Onset
•Abrupt onset •Acute, rarely >1 month•Usually reversible•Disorientation early•Fluctuates hourly•Altered & changing level of consciousness•Short attention span•Variation in sleep cycle•Marked psychomotor changes
•Gradual onset •Progress over years•Generally irreversible•Disorientation later•More stable day to day •Consciousness not clouded until terminal•Normal attention •Day-night reversal•Psychomotor changes late
Delirium vs Dementia
Age of onset
Characteristics
Impaired executive function Memory impairment Disturbed judgment Other disturbances of higher
cortical functions (aphasia, agnosia, apraxia)
Personality change Delirium must be excluded
BPSD
Parenchymal disease of CNS AD, PD, Pick’s, Huntington’s, MS
Systemic disease Thyroid disease, Hypoglycemia,
Hypoxia, Encephalopathy, Multi-infarct dementia
Nutritional deficiencies Drugs and toxins Intracranial pathology Infectious
Creutzfeld-Jacob, Cryptococ, TB, HIV, Neurosyphilis
Causes
THINK! From top to bottom Head: CAT/MRI for tumours,
infarct, NPH etc Chest: ECG, X-Ray for heart &
lungs Abdomen: bloods for liver, kidney,
pancreas General: FBC etc for infections,
anaemia, deficiency states LP only with high suspicion index
Diagnosis
Make an etiological diagnosis Disease specific management Management of behavioral problems Prevent of complications Support of the family Include:
Social worker Occupational therapist Physiotherapist Lawyer Nursing personnel
Management
Non-pharmacological: Mild to moderate dementia:
cognitive stimulation Pharmacological:
Acetylcholinesterase inhibitors donepesil, galantamine, rivistigmine
Memantine (NMDA antagonist)
Management: Cognition
Non-pharmacological: Less expensive, no side-effects Identify behavioral problem and
what precipitates it Nursing plan to curb the behavior Cognitive & behavioral therapy Interpersonal therapy Reality orientation Exercise and activities
Management: BPSD
Consider a cholinesterase inhibitor Avoid anticholinergics Antipsychotics for psychosis,
aggression, agitation, restlessness Haloperidol( Serenace) 0,5 – 2mg Risperidone(Risperdal) 0,25 –2mg
Antidepressants for depression, anxiety, sleep disturbances
Anticonvulsants for agitation, aggression, irritability
Management: BPSD
Elderly persons often present with confusion, either primarily or when being treated for illness and post operatively
NB is to distinguish between: Delirium: medical/neurological
emergency: find cause and treat Dementia: must exclude treatable
causes early: refer for specialist management initially
Context in block SA8