The Confused Elderly Patient

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

8. 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

9. 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

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

11. Dementia

12. Onset

13. Delirium vs Dementia

14. Age of onset

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

16. BPSD

17. 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

19. 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

20. 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

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

23. 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

24. 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

25. 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