Revision Guides
Elderly Care medicine
Confusion & Dementia
Dizziness & Syncope
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Definition: Progressive global decline in intellectual & memory function interfering with social/professional activity
Epidemiology: 10% of 65+. Rises sharply with age
Risk factors: Low level of education, age, Family history, head injury



Usually from 3rd party.
Psychiatric (pseudodementia = depression) 
Cardiac risk factors (it is thought that vascular deterioration plays a part in Alzheimers). IQ (can mask sx).
Early features: Loss of recent memory (long-term goes last). Impairmeent of judgement. Changes in personality. Disorientation in time & space. Anxious/irritable/depressed personality.
Later features: Expressive and then receptive aphasia. Hygiene & behaviour including wandering, aggression, disinhibition. Reduced level of activities of daily-living (ADLs). Incontinence. Loss of insight, visuospatial deficiency, apraxia.




Common: Alzheimers, vascular dementia
Less common: Lewy-body, fronto-temporal, Downs, tumour, extrapyrimadal, Huntingtons
Reversible: Normal Pressure hydrocephalus, alcohol abuse, neurosyphilis, hypothyroidism, Vit B12 deficiency, pseudo-dementia, neoplasms

Alzheimers (70%) Dementia

Epidemiology: in the young ♂=♀. In the old ♂<♀. Unremitting.
Risk factors: 2 copies of ApoE E4 allele on ch19
Pathology: Sev atrophy with increased siize of ventricles & widened sulci. Microscopically neurofibrillary tangles & senile plaques seen. 
Diagnosis: history and CT showing atrophy
  1. Explanation, advice, support of relatives
  2. Multidisciplinary: societies, social services, psychiatrists
  3. Medical: cholinesterase inhibitors (galantine, dorepezil, rivastigmine), memantine
Prognosis: 2-10 years after diagnosis. Patients often die of aspiration pneumonia as they lose coordination of the swallow reflex in the latter stages. Also UTIs and pressure sores.

Lewy Body (10%)

Definition: Widespread Lewy bodies in cerebral cortex
Clinical: Parkinsonism features (but unlike parkinsons these patients present with dementia), progressive dementia, fluctuation in mental state, early visual hallucinations & behaviour disturbance.

Vascular (5%)

Abrupt onset, step-wise deterioration. Cognitive impairments (selective & uneven), minor neuro signs (dysphasia or hemiparesis), confusion, episodes, headache & dizziness, underlying vascular disease (e.g. DM). Personality is preserved until late.
Investigations: CT (infarction, small vessel disease)
Treatment: Underlying cause (cardiovascular risk factors such as cholesterol), low dose aspirin

Frontotemporal (Pick's)

Epidemiology: age range of 45-65 years.
Frontal features:  change in personality, ↓judgement/responsibility/planning, inappropriate sexual/theft, mood swings, preference for sweet foods.
Temporal features: fluent aphasia + fluent speech with no content & lots of “things”, impaired everyday memory. Delusions + hallucinations seen early. Prognosis 5-10 years.

Acute confusion/Delirium

Definition: Global acute disruption of cognitive function. Usually changes in conscious level. Responds well to treatment.
Relationships: Half of those with delirium have dementia


Clouding of consciousness, impairment of orientation, failure of recent memory, poor concentration, visual hallucinations, fluctuations with lucid intervals. Abrupt onset.


Many causes including:


  1. Underlying cause
  2. Avoid sedation: causes falling & ↓respiration
  3. Small dose antipsychotic may be useful but unlicensed for this purpose: consider if it is in the best interest of the patient
  4. Structured routine: same nurses, visits by family, ↓noise, dim lights at night, help feeding
  5. Stimulation: including music and books
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