Approach, management patient with following conditions: Delirium Dementia Fall-risk assessment Tremors med_students0

1. WADA
 Presenter :Dr. anas alsaab
 Commom Geriatric Problem

2. Approach, management patient with following conditions:
 Delirium
 Dementia
 Fall-risk assessment
 Tremors

3. Acute period of cognitive dysfunction owing to a medical disturbance.
Syndrome of disturbance of consciousness accompanied by changes in attention
not accounted for by preexisting dementia.
It can persist for weeks to months
Delirium
 Risk factors
Use of restraints
Four or more medicines in 24 hrs
New/strange environment
Use of indwelling urinary catheter or any line
History of dementia, stroke, or
Parkinson’s Disease

4. Reduced sensory input: poor vision, poor
hearing
Drugs (toxicity & withdrawal, increased
dosages or interactions)
Intracranial: infection, tumor, stroke,
hemorrhage
Electrolyte disturbance dehydration, sodium
imbalance
Infection: urinary and respiratoryLack of drugs, liver disease
Urinary retention/fecal impactionMyocardial and pulmonary: myocardial
infarction (MI), arrhythmia.
 Causes of Delirium

5. Diagnosis :
 Obtain a thorough history from individuals close to the patient to determine the frequency
and duration of mental status changes.
 Ask about alcohol and prescription and illicit drug use, as withdrawal can precipitate delirium.
 Review medications. Steroids, benzodiazepines, hypnotics, anticholinergics, and TCAs are
common causes of delirium.
 Review complete physical exam, with assessment of vital signs and O2 saturation.
• Imaging: Head CT may be indicated for high-risk patients (eg, those with head
trauma or focal neurologic findings) or when etiology cannot be established.
• Complete blood count (CBC), electrolytes, renal function tests, urinalysis, urine toxicology,
blood alcohol level, liver function tests, serum medication levels, arterial blood gases,
• Chest radiographs, electrocardiogram (ECG), and selected cultures can be helpful.

6. Bedside tool: confusion assessment method:
 Delirium involves four key features:
1. Inattention (Decrease ability to focus, shift or sustain attention)
A disturbance of consciousness; decreased clarity of awareness of the environment.
AND
2. Presence of acute onset (hours to days) and fluctuating
AND EITHER
3-Disorganized thinking
OR
4. Altered level of consciousness
Diagnosis of delirium requires features 1 and 2 plus either 3 or 4
.

7. 
 Treatment:
 Identify and treat underlying causes .
 Minimize physical and chemical restraints as much as possible .
 Encourage consistent presence of family or caregivers familiar to the patient, as well as
clocks and calendars to help with orientation .
 Encourage patients to wear eyeglasses and hearing aids, if indicated .
 Target medications for delirium to specific behaviors eg, physical aggression, distressing
hallucinations.
 Low-dose antipsychotics such as haloperidol are preferred in hyperactive delirium
.
 Benzodiazepines are last-line therapy, as they may worsen delirium.

8. 
Dementia is a general term used to describe several disorders that cause significant
decline in one or more of cognitive functioning that are severe enough to result in
functional decline.
Dementia

9. 
• Most common type of dementia
• Clinically characterized by gradual onset with linear progressive decline in cognitive functioning The average
time from onset to death is 5 to 10 years (variable).
• Motor and sensory deficits occur in the late stages of the disease.
The 2 greatest risk factors for AD are advanced age and family history of AD.
Alzheimer disease
 The diagnosis is clinical:
⊚ Memory loss plus one or more of the following:
 Aphasia: Loss of the ability to understand and/or produce language.
 Apraxia: : has difficulty using utensils, tools in the absence of motor or sensory impairment.
 Agnosia: Failure to recognize or identify objects despite intact sensory function, doesn’t recognize familiar
people
 Impaired executive function: Includes the abilities to initiate, monitor, plan, and organize behaviors.

10.  Second most common cause of dementia, 20% to 30% Clinically characterized by
sudden or stepwise decline rather than linear decline in cognitive function
 Risk factors: cerebrovascular accident (CVA).
 Cognitive impairment is patchy (due to preservation of function in non-infarcted parts
of the brain).
 Attention and concentration are often affected.
 Behavioral change and emotional lability are common
 A CT head scan may show evidence of previous infarcts
Vascular dementia

11. 
 Diagnosis:
 Most cases of dementia can be diagnosed on the basis of history from reliable
informant, general medical and cognitive testing .
 Determination of onset and nature of symptoms can help differentiate between
different clinical syndromes
Labs: CBC, glucose, metabolic panel, albumin, LFTs, vitamin B12, UA. Consider VDRL if
patient is at risk for 3° syphilis.
 Imaging: Routine brain imaging is controversial. If obtained, noncontrast CT is usually
adequate and can help identify subdural hematomas, hydrocephalus, and masses.
 Brief quantitative screening tests of cognitive function, such as the Mini Mental Status
Exam (MMSE), may be useful and provide a baseline for future comparison

13. Dementia VS delirium

14. 
Medications :
 Cholinesterase:
• donepezil, rivastigmine, galantamine
• Do not prolong life expectancy but improve morbidity
• Relative contraindications: bradycardia, heart block, arrhythmia, CHF, CAD, asthma,ulcers
and/or GI bleeding
 NMDA (N-methyl-D-aspartic acid) antagonists ( memantine, amantadine) may provide
modest benefit to patients with moderate to severe AD .
 Behavioral symptoms of dementia, such as paranoia, agitation, and irritability, are best
managed by nonpharmacological strategies such as reducing overstimulation.
Treatment
 Discontinue nonessential medications, especially sedatives, hypnotics, and anticholinergics.
 Identify and treat coexisting depression, malnutrition, thyroid dysfunction, occult infections.
 Evaluate for home safety and minimize social isolation; consider screening for caregiver stress.

15. 
 Fall-risk assessment:
• Falls are a major cause of morbidity and mortality among elderly patients,
especially women.
• More than 50% of community-dwelling seniors > 80 years of age fall each year,
and falls are the 6th leading cause of death in the elderly.
.
• A sudden, unintentional change in position causing an individual to land at a
lower level.
• Not caused by paralysis, seizure, or trauma .
• Often multifactorial

16. 
Environmental AssessmentFunctional AssessmentPhysical ExaminationHistory
Environmental assessment
including home safety
Assessment of activities of daily
living :
1-Personal hygiene
Gait, balance, and mobility
levels and lower extremity joint
function
History of falls: Detailed
description of the
circumstances of the fall(s),
frequency, symptoms at time of
fall, injuries, other
consequences
2-Dressing
3. Eating
Muscle strengthMedication review
4 Maintaining continence
5. Transferring/Mobility
Assessment of visual acuityHistory of relevant risk factors:
Acute or chronic medical
problems
Assessment of the individual’s
perceived functional ability
Cardiovascular status
Examination of the feet and
footwear
fall risk assessment include the following

17.  Causes and Treatment of Falls

18. AGS/BGS Falls Prevention Guidelines
⊚ Prescribe exercise, mainly balance, strength & gait training
⊚ Discontinue or minimize psychoactive & other medications
⊚ Mange postural hypotension
⊚ Mange foot problems and footwear
⊚ Supplement vitamin D
⊚ Treat vision impairment
⊚ Manage heart rate and rhythm abnormalities
⊚ Modify the home environment

19. Tremors

• Can be pathologic or physiologic owing to stress normal stimulation of adrenalin
• Involuntary rhythmic muscle contractions of one or more body parts with back-and-forth
movements of the hands, face, eyes, arms, trunk, legs, or voice

20. Treatment
Parkinson disease: A syndrome characterized by resting tremor, bradykinesia, muscular rigidity, and loss of
postural reflexes
The most common cause Can at first be unilateral, can affect the tongue and jaw but not the head,
and usually the tremor is not very obvious in the legs or feet.
Other signs include :, mask-like facies, seborrhea dermatitis, and micrographia
A- Resting tremors
are evident when the affected body part is completely supported against gravity and completely at rest, it
disappears or lessens when the body part is voluntarily in motion.
Levodopa/carbidopa: 1st-line treatment that has been shown to improve all major features of parkinsonism.
Dopamine agonists: Pramipexole and ropinirole may be considered for initial monotherapy in mild disease
MAOIs: Selegiline may be used as an adjunct to levodopa by inhibiting the degradation of levodopa
Surgical measures: Patients who become unresponsive to medical treatment or have intolerable side effects may be helped by
brain stimulators or thalamotomy or pallidotomy

21. 
B-Postural tremors are seen when the arms or head are positioned against gravity,
for example, hands are held straight out in front of the patient.
Essential tremor:
• The most common neurologic cause of postural tremor Frequency increases with age.
• Occurs in up to 5% of the population Familial 50% of the time Tends to be symmetrical,
and can cause head tremor.
• It can affect the voice, chin, and trunk. It rarely affects the legs.
• Worse at the end of a goal-directed activity such as finger-to-nose testing.
• Caffeine does not worsen but small quantities of alcohol reduce the tremor

22. 
C-Kinetic tremors include action and intention tremors .
Action tremors: unchanged during the voluntary movement Essential tremors are action and postural tremors.
Primary writing tremor: exclusively while writing and not during other voluntary acts. Treatment is with
anticholinergic drugs and not propranolol .
Intention tremors:
• increase during the course of goaldirected movement; occur owing to upset anywhere along the cerebellar
outflow pathway from the cerebellum to the thalamus.
• Causes include midbrain stroke or trauma, multiple sclerosis, Wilson disease, mercury poisoning, and
hepatocerebral degeneration.
• Tremor worsens as hand moves closer to its target.

24. 
1-An 80-year-old male is admitted to the hospital for pneumonia. He develops what the nurses
describe to you as “sundowning” behavior that includes nighttime disorientation and some
mild agitation. His wife says he is not like this at home. During morning rounds he is pleasant
and answers questions appropriately except he forgets why he is in the hospital. His
examination, including a neurologic examination, is normal except for crackles on chest
auscultation consistent with the pneumonia. He is not able to say the days of the week
backwards. Which one of the following is most likely in this patient?
A)Alzheimer’s disease
B) Delirium
C) Vascular dementia
D) Encephalitis
E) Stroke

25. ANSWER: B
A diagnosis of delirium based on the Confusion Assessment Method (CAM) algorithm
requires the presence of an acute onset and a fluctuating course, inattention, and
either an altered level of consciousness or disorganized thinking. The patient described
in this question exhibits an acute onset, fluctuation, inattention, and an altered level of
consciousness. This patient’s presentation is more consistent with delirium than
encephalitis, as patients with encephalitis frequently have signs of systemic illness such
as fever, lethargy, seizures, and neurologic deficits, as well as a nonspecific rash in some
cases. Furthermore, the fluctuations in the level of consciousness seen in delirium do
not occur with encephalitis. Vascular dementia and Alzheimer’s disease develop over
years, not acutely as in this case. Stroke, while a consideration and a potential cause of
delirium, would not be the most likely diagnosis in an older patient hospitalized with
pneumonia.

26. 2-While making rounds at a nursing home you see a 70-year-old female with dementia.
The staff tells you that she has recently developed serious aggressive behaviors that
include lashing out physically at caregivers on a regular basis.
Nonpharmacologic interventions have not curbed her violent outbursts. Your evaluation
does not reveal any treatable underlying conditions.
After a conversation about risks and benefits with her family and the nursing
home staff, which one of the following would you recommend for this patient?
A-Diphenhydramine (Benadryl)
B) Aripiprazole (Abilify)
C) Clonazepam (Klonopin)
D) Mirtazapine (Remeron)
E) Ziprasidone (Geodon)

27. 
ANSWER: B
Although the FDA has not approved the use of antipsychotics for aggressive behavior associated with dementia,
they are often used to treat refractory behavioral and psychological symptoms of dementia. Their off-label use
should be considered only when nonpharmacologic therapies are ineffective and the behaviors pose a risk of harm
to the patient or others (SOR C), and the drug should be discontinued if there is no evidence of symptom
improvement (SOR A). In a meta-analysis of three atypical antipsychotics, only aripiprazole showed small average
reductions in behavioral and psychological symptoms of dementia. Olanzapine has demonstrated inconsistent
results and ziprasidone is ineffective. Diphenhydramine is an anticholinergic agent and could exacerbate behaviors.
Mirtazapine is indicated for depression. The American Geriatrics Society recommends against the use of
benzodiazepines in older adults as a first choice for insomnia, agitation, or delirium.

28. 3-You are seeing a 78-year-old man who was brought to the office by his daughter. The daughter
says her father is becoming increasingly forgetful. His medical history is significant for a 20-year
history of type 2 diabetes and well-controlled hypertension. On examination, he is mildly
hypertensive with otherwise normal vital signs. He is oriented to time, place, and person, but is
unable to complete “serial sevens” on a mini-mental status examination. Which of the historical
features make this diagnosis more consistent with dementia as opposed to delirium?
a. His history of hypertension
b. His history of diabetes
c. His current level of orientation
d. His inability to complete serial sevens
e. The recent onset of his symptoms

29. The answer is c. Dementia is an acquired, persistent, and progressive
impairment in intellectual function with compromise of memory and at
least one other cognitive domain. This may be aphasia, apraxia, agnosia,
or impaired executive function. In dementia, the level of consciousness is
not clouded, but disorientation may occur later in the illness.
Hypertension and diabetes may be seen with both delirium and
dementia.
The inability to complete serial sevens (count backward from 100 by 7s)
may be related to dementia, but may also have to do with the patient’s
baseline educational level. Although his symptoms have appeared
recently, it is often difficult to pinpoint the exact onset of dementia.
Delirium is seen as being more abrupt in onset.

30. 4-You are caring for a 72-year-old hospitalized man who is currently 1 day out
from a carotid endarterectomy. You are called to the floor at 3 AM because the
patient removed his peripheral IV and is demanding to go home.
Reviewing his chart, you see that he has a history of hypertension and
hyperlipidemia, both of which are well controlled with medication. He is working
part time as an auto mechanic and lives at home with his wife. On evaluation, he
is agitated but responds to questions, is oriented to person only, and denies
chest pain, palpitations, shortness of breath, dizziness, or other problems. Which
of the following characteristics points to delirium instead of dementia in this
case?
a. The acute onset of his symptoms
b. The fact that he is disoriented to time and place
c. His history of hypertension d. The fact that he is responsive to questions
e. The fact that this happened in the early morning hours

31. The answer is a. Delirium and dementia are often clinically difficult to distinguish,
especially if you are unfamiliar with the patient. Disorientation is characteristic of
both processes, as is a disturbed sleep-wake cycle. His history of hypertension
would lead one to think of multi-infarct dementia, rather than delirium.
Responsiveness to questions may be a feature of either process, though patients
with delirium often have a shortened attention span.
Delirium and dementia both can cause disorientation in the early morning hours,
and therefore timing does not point to one or the other diagnosis. The abrupt
onset of a mental status change is consistent with delirium as opposed to
dementia, which occurs insidiously

32. 5-You are caring for a 45-year-old man who comes to see you with a chief complaint that “my
hands are shaking.” He noted it around 4 months ago, and although it is not progressing, he is
worrying about it. He describes bilateral hand involvement, and he notices it most when he tries
to pour liquid into a glass or drink from a glass or can.
He denies caffeine and drug use, is on no other medications and has no other medical problems.
Interestingly, he notes that when he drinks alcohol, the tremor improves significantly. Based on
these characteristics, which of the following tests should you order to help diagnose the tremor?
A chemistry profile
b. A CT scan of the head
c. An MRI of the head
d. An EMG
e. No testing is necessary

33. 
The answer is a
.The patient described in the question has an essential tremor, the most common
movement disorder. It is characteristically bilateral, starts in the hands, and will change
with age. It is more noticeable in times of stress or fatigue. Alcohol ingestion has a
positive effect, and sometimes eliminates the tremor completely. Laboratory testing in
this case is not for diagnosis, but primarily to rule out other causes, or when a patient
presents with atypical symptoms. Routine laboratory tests that should be ordered include
thyroid function testing, liver function tests, electrolytes, calcium, magnesium,
phosphorous, and blood glucose levels.. A CT or MRI should be used if there are
suspicions for MS or Parkinson disease,

34. 

Diagnosis of delirium requires features 1 and 2 plus either 3 or 4.

36. 
https://sbgg.org.br//wp-content/uploads/2014/10/2010-
AGSBGS-Clinical.pdf
Step Up to Medicine
First aid for the Family medicine
TheStorm2019
Toronto Note 2018
Current Diagnosis and Treatment 4th edition

37. 
 Presenter Dr. anas alsaab