Mini- case (1) – Dementia and delirium

Dr Adam Feather – Lead for Medicine for the Elderly

Mini-case (1)Mr Richard Lewis is a 79 year old retired train driver. He is attending the outpatient clinic with his wife for the first time. The letter from his GP states that apart from hypertension and benign prostatic hypertrophy (BPH), for which he had a TURP some five years ago, he has been very well and independent. His wife brought him to the GP surgery at her ‘wits end’saying she could no longer live with him and that ‘he was driving her round the bend’. After a lengthy consultation it seemed the main problem was Mr Lewis’memory. The GP apologised for the rather ‘detail free’letter but hoped you would be able to ascertain a better history.

(1) What questions would you like to ask regarding Mr Lewis’ memory problems?

Mini-case (1)May need to take separate histories from patient and relative (with permission). The Hx should be directed at (a) making / confirming a diagnosis and (b) excluding reversible or treatable causes e.g. depression, cerebral mets, B12 and folate deficiency, hypothyroidism

HPC – Onset, progression and pattern of deterioration, things that patient has noticed (insight), things that wife has noticed about memory e.g. what he is finding difficult (ADLs); ‘Functionality’

Cardiovascular risk – IHD, Stroke, PVD, DM, Hypertension, Smoking, alcohol excess, lipids

PH – Head injury, CNS disease, mental healthFH – dementia, Premature CV deathDH – Antiplatelets (CV protection), anti-psychoticsSH – occupation, education, social support, ADLs and functionROS – general health (see above)

Mini-case (1)Mrs Lewis explains that he has been slowly deteriorating over the past 2 years and that it is now ‘impossible to live with him’. He cannot remember even simple things such as the way to his bowls club, which is just around the corner from their home.The SpR examines Mr Lewis his BP = 160/90 but otherwise general, CVS, RS, abdominal and neurological examinations are all within normal limits.

(2) Under the following headings think of a question or test for the patient to perform to test their ‘memory’.

Long term memory Short term memory Language skills Draw a shape Concentration Executive function

Folstein (MMSE)Long term memory – Place – Country, Town, Area, (Building)

Short term memory – 3 objects ( repeat, 5 minute)

Language skills - Write a sentence; follow 3 stage command

Draw a shape - intersecting pentagons

Concentration – serial 7s, WORLD / DLROW

Executive function – None!Folstein MF, Folstein SE, McHugh PR; "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189-98.

Mini-case (1)Mr Lewis scores 6 / 10 and 21 / 30 on the AMTS and the MMSE respectively, principally losing marks on short term memory and orientation tests. The SpR tells Mr and Mrs Lewis that she will need to send Mr Lewis for several tests including blood, radiology and a few others.

(3) List the tests you would include in each of the categories listed above, with a reason or reasons for each.

Mini-case (1)As with the history, investigations are directed at (a) excluding contributing or treatable causes of cognitive impairment and (b) confirming the diagnosis.

Bloods – FBC, U&Es, CBG, Lipids, ESR, TFTs, LFTs, Calcium / magnesium, VDRLRadiology – CXR and CT head scanOthers - ECG

Mini-case (1)His investigations including FBC, U+Es, RBG, LFTs, cCa, TFTs, ESR, VDRL, CXR and ECG are relatively unremarkable other than some signs of LVH on his ECG and cardiomegaly on his chest radiograph. The CT head scan shows ‘generalisedcerebral atrophy with no signs of SOL or previous stroke disease’

(4) What is the most likely cause for the signs of LVH on the ECG?

(5) What is the most likely cause for the cerebral atrophy on the CT head scan?

‘LVH with strain’

Mini-case (1)The SpR discusses the results with Mr and Mrs Lewis and tells them he probably has Alzheimer’s disease. She recommends he starts on a ‘new medication’ which has been shown to slow the deterioration of the disease.

(6) List two possible ‘new medications’ with their side effects. (7) You may also need to add another medication in view of his BP =160/90. List another medication and its side effects. Do these two medications interact?

Mini-case (1)Drugs can only be prescribed by ‘expert’ – geriatrician, psychiatrist or neurologist with a specialist interest (see NICE guidelines in BNF):

• Donepezil – reversible Acetylcholinstesterase inhibitor – SEs- GI – N&V, diarrhoea, halucination, agitation, insomnia, Peptic ulcers (rare), SAN and AVN block

• Galantamine - reversible Acetylcholinstesterase inhibitor and some Nicotinic receptor agonist effects; SEs – similar to Donepezil – also may induce IHD and Stroke, hypokalaemia, V. rarely: GI bleed, parkinsonism, dysphagia

• Rivastigmine - reversible Acetylcholinstesterase inhibitor – similar side effect to above including PUdx, parkisonism, bradycardia

• Memantine – N-Methyl-D-Aspartate (NMDA) – Receptor antagonist;Same group as Ketamine. SEs – headache, hypertension, constipation, abnormal gait. Psychosis including hallucination and suicidal ideation (very rare)

• Anti-hypertensives – A – C or DBendrofluomethiazideACEIs – Perindopril, Rampril, LisinoprilA2RB – Losartan, ValsartanBeta-blockersCalcium channel blockersDoxazosin

Mini-case (1)

The SpR discusses the home circumstances with Mrs Lewis and the current difficulties that she is having.

(8) How would you help both Mrand Mrs Lewis maintain Mr Lewis at home?

Mini-case (1)• Therapeutic interventions including

reducing CV risk• Assessment of ADLs• Assessment of home situation• Dementia support; Respite – sitting

service, week(s) respite• Day centre / Luncheon club• Support for Mrs Lewis

Mini-case (1)Three months later, Mrs Lewis is woken in the middle of the night. She finds Mr Lewis getting dressed, mumbling that he had forgotten to take the dog for a walk. When she tells him that they don’t have a dog and tries to get him to return to bed, he becomes agitated and starts shouting. Mrs Lewis cannot make sense of what he is saying, and she feels frightened. She notices that he has been incontinent of urine. She calls the out-of-hours GP service, and an on-call GP visits them at home.

(9) What is the diagnosis?(10) What do you think the GP should do when he reviews Mr Lewis, and why?

Mini-case (1)• This is acute on chronic confusion = Delirium;

there are many many causes including- Sepsis - Metabolic- Medications (inc withdrawal)- Toxins – alcohol- CNS – Causes of raised ICP; stroke; seizure

• The patient needs admission and further investigation

Mini-case (1)Mr Lewis is sent up to the ED for admission to hospital. He is clerked in by the FY1 for Medicine for the Elderly. On examination she finds tachycardia (pulse rate 136bpm, poor volume and irregular) and coarse crepitations in the left lung base. The FY1 organizes some investigations and arranges his admission.

(9) What investigations would you order, and why?(10) What do you think are the most likely diagnoses?(11) What would be your management?(12) Write up your management on the charts provided.

Mini-case (1)(9) Bloods – FBC, U&Es, RBG, LFTs, Blood

cultures x 2; ?CR(A)P,Sputum – MC&S; UrinalysisCXR, ECG, Venous or ABGsCT head scan – if no improvement or focal deficit

(10) Implied diagnoses – left lower lobe pneumonia; Fast AF with resulting delirium

(11) Admit, CHEMO-IV (!) - Fluids, IV antibiotics, sc heparin, IV digoxin or similar for Fast AF

What and where is the lesion?

List 5 abnormalities of the ECG

Mini-case (1)After a slow recovery the team feel that Mr Lewis is ready for discharge. However whilst planning for home Mrs Lewis and her daughter visit the ward and tell the nurse in charge that they feel Mr Lewis needs to go into a home as ‘they can not manage him anymore’. When asked on the consultant ward round the next day Mr Lewis is insistent that he wants to go home. His MMSE is 21/30.

(13) How would you proceed?

Mini-case (1)• Need to establish patient’s capacity – see

next slides• If he retains capacity his wishes need to

be facilitated; however – the family will need support, so a negotiation around his level of care and support will need to take place

• If no common ground / compromise can be attained – a CPM will need to be held.

• Regardless Mr Lewis will need full MDT assessment +/- home visit.

Mini-case (1)(14) What do you understand by the

following terms?(a) Mental capacity(b) Enduring Power of Attorney

(EPA)(c) Court of protection

Capacity• Important changes were brought in around capacity by

the Mental Capacity Act (2005) – (see links at the end of the presentation).

• All individuals are assumed to be mentally competent and retain capacity until proven otherwise.A person lacks capacity if they fail one of the following criteria: (a) understanding the information relevant to the decision (b) retaining the information (even if only for a short period) (c) using or weighing that information (d) communicating the decision (by any means)

• An unwise or irrational decision is not necessarily an incompetent decision.

• Individuals who do not have an advocate, require assessment through the IMCA service (Independent mental capacity advocate).

Enduring Power of Attorney• This is a legal process• A competent Individual gives the legal right to

one or more individuals (= ‘attorneys’) to manage their financial affairs including property

• Unlike an ordinary power of attorney, an EPA remains effective even if the individual becomes mentally incompetent at a later date.

• An EPA can NOT be put in place once a person loses capacity

see: http://www.enduringpowerofattorney.co.uk/

The Court of ProtectionThe Court has the same powers, rights, privileges and authority in relation to mental capacity matters as the High Court. It is a superior court of record and is able to set precedents (set examples to follow in future cases).

The Court of Protection has the powers to: • decide whether a person has capacity to make a particular decision

for themselves; • make declarations, decisions or orders on financial or welfare

matters affecting people who lack capacity to make such decisions; • appoint deputies to make decisions for people lacking capacity to

make those decisions; • decide whether an LPA or EPA is valid; and • remove deputies or attorneys who fail to carry out their duties, and • hear cases concerning objections to register an LPA or EPA and

make decisions about whether or not an LPA or EPA is valid.

See http://www.publicguardian.gov.uk/about/court-of-protection.htm

Mini-case (1)•http://www.sign.ac.uk/pdf/sign86.pdf

BGS guidelines on the diagnosis and management of patients with dementia

• http://www.nice.org.uk/CG042The NICE guidelines for care of patients with dementia

http://www.dh.gov.uk/en/Publicationsandstatistics/Bulletins/theweek/Chiefexecutivebulletin/DH_4108436Summary of Mental Capacity Act (2005)

http://www.bgs.org.uk/Publications/Compendium/compend_2-2.htmBGS guidelines on capacity

Mini-case (1)

http://www.patient.co.uk/showdoc/40000152/Really good guide to MMSE