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The Confused Elderly Patient

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”.

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The Confused Elderly Patient

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  1. The Confused Elderly Patient Dr C Kotzé Dept of Psychiatry 2012

  2. 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”

  3. Delirium

  4. 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

  5. Characteristics • 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

  6. Causes • Infection (chest &UTI) • Heart failure • Metabolic disturbance • Cerebro-vascular disease • Drug administration • Drug withdrawal (alcohol, BZ • Hypothermia • Any severe illness

  7. Management • 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

  8. 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

  9. Pharmacological • Haloperidol 0,5mg bd • If severe restlessness: • Lorazepam 2-4mg IMI q6h • In substance withdrawal delirium: • Withdrawal regime of long acting BZ

  10. Dementia

  11. Onset

  12. Delirium vs Dementia

  13. Age of onset

  14. Characteristics • Impaired executive function • Memory impairment • Disturbed judgment • Other disturbances of higher cortical functions (aphasia, agnosia, apraxia) • Personality change • Delirium must be excluded

  15. BPSD

  16. Causes • 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

  17. Diagnosis • 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

  18. Management • 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

  19. Management: Cognition • Non-pharmacological: • Mild to moderate dementia: cognitive stimulation • Pharmacological: • Acetylcholinesterase inhibitors donepesil, galantamine, rivistigmine • Memantine (NMDA antagonist)

  20. Management: BPSD • 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

  21. 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

  22. Context in block SA8 • 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

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