04.02 Neuro
04.02 Neurodegenerative disorders [PDF link]: Vascular dementia, Alzheimer’s disease, Lewy body dementia (LBD), Frontotemporal degeneration (incl Pick’s disease), Delirium, Normal pressure hydrocephalus
External links
Abbreviated mental test: AMT4 (MDCalc) & AMT10 (MDCalc)
4As test for delirium screening: MDCalc
Mini-mental state exam (MMSE): PsychDB (random website but has the pdf file for the test)
More on delirium / confusion
Use 4AT as a “triage” tool of sorts
Causes of delirium – “PINCH ME” mnemonic from British Geriatrics Society
Pain
Infection
Nutrition
Constipation
Hydration
Medication & Metabolics
Environment
Screening for causes [≈ Confusion screen] – recommendations from NICE CKS
A-E exam – look for causes of pain, sources of infxn
DRE – always r/o constipation!
Bloods: FBC, U&Es, LFTs, CRP, bone profile, B12&f0late, haematinics, HbA1c, TFTs
Urine MCS (not dip as unreliable in elderly)
Viral throat swab
CXR
Sputum MCS if productive cough
Blood glucose
± ECG
± Drug levels if concerns
± CT head if concerns regarding acute change in GCS / mental status
Treatment / prevention of delirium
Pain – analgesia (beware opioid overdose)
Infection – treat source if found
Nutrition – encourage PO intake, involve dieticians, family, etc
Constipation – DRE + laxatives
Hydration – encourage PO intake, otherwise may need IV fluids
Medication – remove potential causes of confusion unless unable to
Metabolic – correct sugars, electrolytes
Environment – try to nurse in familiar environment and faces, with natural light, with clock, etc
Patients may require deprivation of liberty safeguarding (DoLS) if they lack the mental capacity to make decisions for treatment
Pharmacological options should only be considered if patients are at risk to themselves (or more rarely to others)
Haloperidol 0.25-0.5mg, max 2mg in 24h
Lorazepam 0.5mg, max 2mg in 24h
Quetiapine 25 mg, max 50 mg in 24h – alternative to haloperidol in LBD/Parkinson’s
See more in this article from BMJ as well
