Confusion in the Elderly

Objectives

·       
Common causes of confusion in elderly

·       
 Recognizing risks and
preventions

·       
Work up for delirium

·       
Management of behavioral problems

 

Delirium

—  Is a state of confusion when
there is a fluctuating altered level of consciousness (reduced awareness of
surroundings, memory deficit) with inattention to environment that develops
over short period of time

—  Delirium = Confusion + Altered
level of consciousness

Why delirium is important?     

—  Common in elderly

—  Needs hospital admissions

—  Ortho and ICU related costs 

—  Cognitive drop

—  Morbidity – Death

Case Study

—  79 years old lady

—  Usually Slight forgetful as per
her daughter but now more confused. Lives with her daughter 

—  PMH: HTN, Depression, GORD,
Insomnia

—  Medications:

—  Amitriptyline          

—  Lansoprazole

—  Zopiclone

—  Indepamide

Case study

—  Tripped over carpet

—  Hospitalized with fracture
neck of femur

 

Delirium verse Dementia

Delirium

—  Acute

—  Inattention

—  Altered conscious level

—  Fluctuations/minutes

—  Reversible

—  Hallucinations common

 

 

Dementia

—  Gradual

—  Memory disturbance

—  No LOC

—  No Fluctuations

—  Irreversible

—  Hallucinations common only
in advanced disease

 

Causes of Delirium

 

—  Infection (UTI, Pneumonia,
Cellulitis, abscess)

—  Withdrawal – Medications, Alcohol

—  Medications review  (regular, PRN, OTC)

—  Acute metabolic Trauma –
electrolyte imbalance (hyponatremia)

—  CNS pathology

—  Hypoxia from COPD
exacerbations/CCF

—  Pain

—  Constipation

—  Urinary retention

—  Psychomotor illness – comorbid
conditions

—  Cancers

—  Stroke

Medications Associated
with     Confusion in the Elderly

—  Analgesics               

—  Antihistamines                   

—  Anti-hypertensive
(BNF-hyponatremia)                     

—  Anti-parkinsonian drugs              

—  Cardiovascular drugs        (digoxin toxicity)   

—  Hypoglycemics                   

—  Psychotropic drugs                       

—  Anxiolytics   

—  Antidepressants     

—  Antipsychotics        

—  Hypnotics                

—  Miscellaneous                    

—  Cimetidine (Tagamet)      

—  teroids          

—  induced psychosis

Confusion assessment
tools

—  History

—  Examination

—  AMTS – 10 Question

—  MMSE – 30 Question

—  6CIT test

—  Year

—  Month

—  Address

—  Time within one hour

—  Count backward from 20

—  Months of year in reverse

 

Clinical signs 

—  Vitals (high temp, low sats)

—  Good physical exam

—  Hydration status

—  Try to rule out common causes first (always remember common things are common)

Lab Work Up

—  Blood glucose

—  FBC, U&E, CRP, LFT, Calcium, TFTs, B12

—  Urine dip test

—  CXR +/- Blood cultures

—  Other investigations

—  CK (long lie)

—  CT head

—  Drug levels (digoxin, lithium) 

Delirium reduction

—  Simple Aids

—  Glasses

—  Hearing aids

—  Walking aids

—  Fluids

—  Nutrition

—  Familiar faces

—  Familiar environment

—  Medications review / avoid poly-pharmacy

—  Avoid sleep deprivation (day night pattern)

Management

—  To calm the patient sufficiently

—  Treat the cause -?infection/drugs

—  In severe agitation: haloperidol 0.5-1mg

—  Review patient and medications – always arrange follow up 

Medications review

 

—  Benzodiazepines (avoid in combination with antipsychotics)

 

Dementia

—  Very common

—  >65 years – dementia screen

—  Arrange CT head if symptoms persist

Types of Dementia

—  Alzheimer’s Disease

—  Vascular dementia (Small Vessel Disease /Amyloid Angiopathy)

—  Lew Body Disease

—  Parkinson’s Disease Dementia

Care of people with dementia

—  Donepezil (Aricept) is cholinesterase inhibitors which has been approved for use in treating dementia.

—  Management of people with dementia

—  Exercise, stimulate the brain by music or cross words or reading

—  Awareness to carers/family

—  Incontinence – urinary and fecal (wearing pads)

—  Bed sores