The Confused Elderly Patient Dr C Kotzé Dept of Psychiatry 2012

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