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NADEEN ISMAHEL FY1 FALLS,DELIRIUM,DEMENTIACONTENTS FALLS DEMENTIA DELIRIUM Scenario Types Types Common causes Investigations Investigations Assessing a fall Management Management Investigations Compare and contrast PlanYEAR4ILO SYEAR4ILO SFALLS man who has had a fall on the ward.eeped during your night shift to see Mr Smith a 79 y/o What are some questions you’d like to ask the nurse during the call before seeing Mr Smith? - Was the fall witnessed? - What are his observations? - Did he hit his head when he fell? - Is he on any anticoagulants? - Did he sustain any obvious injuries?F-LMedication: polypharmacy, anti-hypertensives, sedatives, hypoglycaemic agents - Poor balance: Parkinson’s, muscle atrophy, joint instability, poor vision, vertigo - Environmental: Poor lighting, trip hazards, inappro, mobility aids - Infection: Urinary, chest - Cardiovascular: Arrhythmia, bradycardia, valvular heart disease, orthostatic hypotension - Neurological: Stroke, seizure, peripheral neuropathy - Metabolic: Hypoglycaemia, alcohol excess FALLS Scenario: You’re an FY1 and you get bleeped during your night shift to see Mr Smith a 79 y/o man who has had a fall on the ward. Background: Admitted one week ago with a UTI, completed course of antibiotics PMH: Atrial fibrillation, hypertension Medication: Apixaban (anticoagulant) Atorvastatin (statin) Bisoprolol (beta-blocker) Chlorphenamine (antihistamine) Codeine (pain killer) Losartan (antihypertensive)WHICHOFTHESEMEDICA TIONSCOULDBECONTRIBUTINGTOF ALLS? - Apixaban (anticoagulant) - Atorvastatin (statin) - Chlorphenamine (antihistamine) - Codeine (pain killer) - Losartan (antihypertensive)WHICHOFTHESEMEDICA TIONSCOULDBECAUSA TIVETOF ALLS? - Atorvastatin (statin)nt) - Bisoprolol (beta-blocker) - Chlorphenamine (antihistamine) - Losartan (antihypertensiveMEDICA TIONS - Polypharmacy - Anti-hypertensives - Hypoglycaemic agents -FALLSREVIEW-HISTORY BEFORE DURING AFTER Palpitation? LOC? How long were they out for? SOB? Head injury? How did help come? Dizziness? Which body part took the impact?Drowsy? Chest pain? Seizures? Weakness? Aura? Tongue biting? Post-ictal? Weakness? Incontinence? Pain and obvious injuries? LOC? Trip?FALLSREVIEW-EXAMINA TION OBSERV ATIONS TOP-TOE - BP - lying and standing - GCS - Oxygen sats - sensation, co-ordination, reflexes, tone,, power - RR - Inspect head for haematoma, cuts, bruising - AVPU - Ausculate heart and lungs - pulse - Blood glucose - Abdominal exam - TemperatureFALLSREVIEW-INVESTIGATIONS - ECG: Arrhythmias - Bloods: Infection, electrolyte disturbances, dehydration X-ray: , broken bones - - CT head: intracranial bleed - Cardiovascular investigations: 24 hours tape, ECHO - UrinalysisFALLSREVIEW-BLOODS - FBC - U&Es - CRP - CK - Bone Profile - Haematinics (including B12/Folate) - Vitamin D - TFsFALLSREVIEW-CTHEAD NICEGUIDELINES within 1 hour of the risk factor being identified:ave any of the following risk factors, perform a CT head scan • GCS less than 13 on initial assessment • GCS less than 15 at 2 hours after the injury • Suspected open or depressed skull fracture • Any sign of basal skull fracture • Post-traumatic seizure • Focal neurological deficit • More than 1 episode of vomiting anticoagulant treatment, perform a CT head scan within 8 hours of the injurya CT head scan and who are havingFALLSREVIEW-PLAN VARIESDEPENDINGONTHECAUSE - Neuro obs – if any head injury - If ongoing high falls risk due to confusion, does the patient need 1:1 nursing? - Treatment/correction of any underlying cause - Does their anticoagulation need holding? - Optimising drugs As always – consider if the patient needs escalating to a senior -SUMMARY Many causes for a fall - - Always try to get a collateral history - Always check drug chart - Before, during, after - Top to toe examination Consider CT head - - Escalate if uncertain DEMENTIA an alert person. Signifiant enough to affect daily life.y and other cognitive function in Why is it important? - 1% of 60–65 year olds - >30% of over 85s. Over - Frequent attenders to hospital - Difficult to take an adequate history and examinationDEMENTIA-TYPES - Alzheimer’s disease (60%) - Vascular dementia (30%) - Oe.g. dementia with Lewy bodies, Parkinson’s disease with dementia, fronto-temporal dementia Reversible dementias (<5%), e.g. drugs, metabolic, subdural, NPH -DEMENTIA-TYPES - Alzheimer’s disease - Insidious onset and gradual decline of cognitive functions - Vascular dementia - Stepwise decline in cognitive function - Lewy body dementia - Fluctuating with rigidity and visual hallucinations - Frontotemporal dementia - abnormal behaviour and aphasiaDEMENTIA-REVERSIBLECAUSES Delirium, drugs Electrolytes Mood Eye/hearing Nutrients Thyroid Infection AnaemiaDEMENTIA-INVESTIGA TIONS Dementia can only be definitively diagnosed using a biopsy post-mortem - Bloods - CXR - Head MRI/ CT - Thorough history/ collateral - MMSE <24 - Hearing testDEMENTIA-BLOODS Reversible causes of dementia Bloods Delirium, drugs - FBC Electrolytes - Haematinics Mood TSH Eye/hearing - Glucose Nutrients - CRP Thyroid - B12 and Folate Infection - AnaemiaDEMENTIA-MANAGEMENT MDT - Doctors - Physiotherapists - Occupational therapists - Speech and language therapists - Palliative carellary staff - Social workDEMENTIA-MEDICA TION Mild to moderate dementia (Cholinesterase inhibitor) Donepezil - Galantamine - Rivastigmine Severe dementia (NMDA receptor antagonist) Memantine DELIRIUM An acute complex organic brain syndrome characterised by a fluctuating state of confusion with disturbance of consciousness, cognitive function and psychomoto. behaviour Why is it important? - 10-50% of post surgical patientsrds - Difficult to take an adequate history and examination -DELIRIUM-TYPES HYPOACTIVE HYPERACTIVE MIXED Lethargy Agitated Mix of both or fluctuating Inattention Upset Sleeping AgressiveDELIRIUM-CAUSES Drugs, dehydration, detox (alcohol) Electrolytes (hypercalcaemia, hyponatraemia), environment (esp ICU) Lack of sleep Infection, infarction Renal failure Intoxication, impaction (constipation) UTI Metabolic (hypoglycaemia, thyroid), malignancy (cerebral/paraneoplastic) Surgery DELIRIUM-INVESTIGA TIONS Bloods - History and examination - collateral if posU&Ele - 4AT screen - LFTs - Observations - Glucose - Imaging - CT head, CXR - TFTs - Urinalysis/ culture and sensitivity - Calcium - Blood cultures (if sepsis suspected) - DELIRIUM-MANAGEMENT TREA T UNDERL YING CAUSE Treatment is mostly supportive: - Consistent team, re-orientation and reassurance - Familiar objects - eg photos, books, music, clothes - Clear and concise communication - Make sure they have their hearing aids/glasses/walking stick etc - Try to maintain/encourage regular sleep – minimise waking through night, keeps lights off overnight etc Medication - Drugs can worsen delirium. Consider stopping benzodiazepines or sedating drugs which could precipitate delirium - Small dose haloperidol (0.5mg) is first-line – PO or IM usually - Lorazepam (0.5mg) often used if contraindicated (e.g. heart issues, Parkinson’s, Lewy body)DELIRIUMVSDEMENTIAQUESTIONS?