The Confused Elderly Patient

Dr C KotzéDept 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