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CNSLF Med - Cognitive Impairment (Delirium & Dementia) (ii) (Alz tx…
CNSLF Med - Cognitive Impairment (Delirium & Dementia) (ii)
Alz tx
remove/minimise agents that will impair cognition (e.g. anticholinergics)
cholinesterase i's: donepezil, rivastigmine, galatamine
NMDA R antagonist: memantine
drugs don't reverse or prevent ultimate outcome (no halting) but can possibly delay progression so patient doesn't become dependent as early (might get to stat @ home longer)
manage HTN
avoid alcohol
vaccines
driving? difficult as some patients think there fine, others acknowledge their issues
finances
tend to worry a lot about money + start hiding it
enduring power of attorney - mentally capable person takes over
social support - less in rural, hence faster loss of independence
social interaction
BPSD (behavioural + psych symptoms of dementia) management
OT - may help with memory strategies - e.g, showing patient how to keep a dairy
medical social work
pharmacist
physiotherapist
dietician - patient may need supplements
nursing
neuropsychology (assess mental capacity - NB for future medical decisions)
Delirium
acute confusional state
can happen if you become medically unwell (esp infection)
differentiated from dementia by...
time course
fluctuation (except to Lewy body dementia, dementia doesn't fluctuate from hr ro hr, its progressive)
prominence of impaired ability to shift to maintain attention (delirious patients may forget who you are secondary after you introduce yourself, attention usually normal in dementia except if v severe)
associated general medical illness
altered consciousness in delirium not dementia
reversibility
tx underlying cause
dx often delayed
important to know underlying dx status - should return to baseline
subtypes
hyperactive: visual hallucinations, hyperalert, distractible - better prognosis
hypoactive: drowsy, long periods of apathy or impaired interaction
mixed
common precipitants
UTI
esp in elder women with DM
may have no localising symptoms
patient may be otherwise well
LRTI
sepsis
electrolyte abnormalities (esp Na, hypo>hyper but both can cause it)
medications incl alcohol withdrawal
stroke (look for risk factors e.g. a fib)
MI
intra-abdo bleed (e.g. from PUD)
hip or pelvic fracture
risk factors
age
dementia
Parkinson's
previous stroke
frailty
liver disease
poly pharmacy
alcohol misuse
tx
tx underlying condiiton
stop anticholinergics
manage safety issues: falls, swallowing (aspiration pneumo), medications, DVT (esp with hypoactive)
ideally in single well lit quiet room with family member or 1 defined care attendant/nurse (new faces increase confusion)