Delirium

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Delirium Dementia

• What? When? Why? How? Who?

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Objectives

• Recognize delirium dementia
• Understand the differences between delirium
  dementia
• Effectively manage patients with delirium or
  dementia

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Outline

• Introduction to cognitive impairment
• Delirium
• Dementia
• definition
• epidemiology
• S S/ presentation
• pathophysiology
• diagnosis
• management prognosis
• Summary

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Cognitive impairment/brain failure

• NOT a normal part of aging
• The diminished ability to think
• Failure of a major organ system-the brain
• Not a diagnosis
• gt50 not identified
• Need to use standardized MSE

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What is delirium?

• Acute confusion, transient cognitive impairment,
  clouded state, encephalopathy, ICU psychosis
• acute form of brain failure medical emergency
• Fluctuating cognition
• ATTENTION, mood, arousal, self-awareness
• global cognitive impairment
• reversible
• improves if patient does not die

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What are the S S of delirium?

• Main defect attention --gt
• less aware of surroundings
• easily distractible
• trouble with concentration commands
• Main aspects of cog. disordered thinking,
  perception, memory
• ? sleep-wake cycle, disorientation,? LOC
• ? or? psychomotor activity
• /- emotional ? s and irritability

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Who becomes delirious?

• Elderly
• 10-38 at hospital admission higher in nursing
  homes
• up to 80 hospitalized for acute physical illness
• Surgery
• 10-15 general
• 30 open heart surgery
• gt 50 hip fractures

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What causes delirium?

• Widespread decline in cerebral met.
  derangement of NT
• Several mechanisms likely
• failure of cerebral oxidative mechanisms
• failure of cholinergic neurotransmission
• CNS effects of lymphokines
• Functional rather than structural

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What conditions lead to delirium?

• Primary intracranial pathology
• Systemic disease secondarily affecting the brain
• Exogenous toxic agents
• esp. meds anticholinergics, diuretics, digoxin,
  H2 receptor blockers, antihypertensives,
  antiarrhythmics, benzos, NSAIDs,
  antiParkinsonians.
• Withdrawal from substances of abuse (EtOH,
  sedative/hypnotics)

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What predisposes the elderly to delirium?

• aging processes in the brain
• structural brain disease
• ? capacity for homeostatic regulation/resistance
  to stress/disease
• impaired vision hearing
• chronic disease
• age-related ? s in response to drugs.

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Is there an easy way to remember the causes of
delirium?

• I Infection
• W Withdrawal
• A Acute metabolic
• T Trauma
• C CNS pathology
• H Hypoxia
• D Deficiencies
• E Endocrine
• A Acute vascular/MI
• T Toxins-drugs
• H Heavy metals

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How good are we at recognizing delirium?

• Only 30-50 of affected patients have signs and
  symptoms documented by MDs
• RNs document 60-90
• Even when SS noted, often mistaken for
  depression or dementia

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What are the criteria for delirium?

• Criteria for dx of delirium (DSM IV)
• A . Disturbance of consciousness
• B. Change in cognition or development of
  perceptual disturbance not accounted for by a
  dementia
• C. Development over short period of time -
  usually hours to days tends to fluctuate during
  course of day.
• D. Evidence on hx, PE or lab findings that
  disturbance caused by direct physiological
  consequences of a general medical condition

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How do you diagnose delirium?

• History
• Physical exam - V.S.chest/cardiac/abdomenrectal
  neuro
• MMSE
• Attention
• Speech
• Investigations - CBC, urinalysis, lytes, ca, BUN,
  crt, glu, alb, LFTs, ECG, CXR, cardiac enzymes,
  ABGs
• TSH, folic acid, B12, VDRL
• drug/heavy metal screens, drug levels
• CT/MRI, LP EEG

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How do you manage delirium?

• Establish underlying causes treat
• Then 1. D/C or ? drugs
• 2. Fluids, lytes, nutrition, vitamins, O2
• 3. Supportive nursing care reorientation
• 4. Environment
• 5. Glasses/hearing aids
• 6. Attention to patient concerns fears
• 7. Reassurance of family re transient nature
• 8. Sedation if agitated, restless self-risk
  atypical antipsychotics, lorazepam,
  physostigmine.
• 9. Avoid restraints

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Whats the prognosis in delirium?

• 6-35 die in hospital
• generally full recovery 1/4 ? long term
  cognitive impairment
• ?length hospitalization
• ?rate institutionalization
• ?complications
• - UTI, ulcers, caregiver stress

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What is dementia?

• progressive, non-reversible decline in
  intellectual/cognitive emotional abilities --gt
  impairment in social or occupational functioning
• MEMORY loss, ?ADL, disorientation, difficulty in
  learning, loss of language skills, ?judgement
  planning, personality changes can have
  perceptual changes psychosis.
• apparent/reversible dementia brain failure with
  significant potential for remediation or even
  complete alleviation

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The grey zones

• Normal memory changes with aging age-associated
  memory impairment late life forgetfulness
• vs
• Mild cognitive impairment (MCI) isolated memory
  impairment Cognitive impairment, Not Dementia
  (CIND)

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Does memory change with aging?

• Stable
• remote memory
• crystallized abilities
• remembering gist of info
• Changing
• new learning
• dept of processing
• recall of details of new info/events
• nonverbal memory

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Who becomes demented?

• Epigt 250,000 Canadians
• 2 population aged 65-74
• 11 pop. 75-84
• 34 pop. 85
• moderate to severe dementia - 7.8 of elderly
  4.2 in community 53.7 in institutions.
• Alzheimers 2/3 dementias

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What does the DSM IV say about Alzheimers
dementia?

• A. Development many cognitive deficits
• 1. Memory impairment
• 2. One or more of the following aphasia,
  apraxia, agnosia, disturbance in executive fn.
• B. Significant impairment in functioning and
  decline
• C. Gradual onset and continuing decline
• D. Cognitive deficits not due to other CNS,
  systemic or substance induced conditions.
• E. The deficits do not occur exclusively during
  the course of a delirium
• F. The disturbance is not better accounted for by
  another Axis 1 disorder

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What of dementia is reversible?

• 10 apparent dementia
• D drugs
• E emotional illness
• M metabolic endocrine disorders
• E eye and ear problems
• N nutritional
• T tumour or trauma
• I infection
• A alcoholism

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So how does Alzheimers fit in?

• 2/3 of dementias
• Syndrome - not a single disease
• Genetic predisposition
• Environmental triggers
• Definitive dx on PM or brain bx --gt
  neurofibrillary tangles neuritic plaques
• Neuro exam (exc. MMSE) normal
• Institutionalization 3 yrs death 9 yrs.

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Alzheimers Progression

Deterioration
Cognitive function
Functional autonomy
Mobility
Mood-depression clears early
?
Behaviour agitation sundowning
Time
?
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What are the risk factors for Alzheimers?

• Age
• Family History
• Apolipoprotein E4
• Gender
• Head trauma
• Low education
• Systolic hypertension
• Downs Syndrome

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Lewy Body Dementia

• 15-25 (2nd most common dementia)
• marked cholinergic deficit ?rapid progression
• key features
• fluctuations in cognitive function and level of
  consciousness
• visual hallucinations
• spontaneous motor Parkinsonism
• v. sensitive to neuroleptics

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And vascular dementia?

• 3rd most common cause (15)
• multi-infarct, strokes, hemorrhages
• stepwise decline
• stigmata of stroke
• abnormal neuro exam
• CT/MRI show multiple small some larger infarcts

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What are other types of dementias?

• Fronto-temporal (Picks) - 10
• Parkinsons (25 develop)
• EtOH abuse - 10
• Others - NPH Huntingtons CJD
• Mixed

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Are there complications to dementia?

• Caregiver stress
• Depression
• Behavioural disturbances

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Psst! Wanna buy some drugs?

• Donepezil (Aricept)
• acetylcholinesterase inhibitor
• Rivastigmine (Exelon)
• cholinesterase inhibitor
• acetyl
• butyryl
• Galantamine (Reminyl)
• cholinesterase inhibitor nicotinic modulator

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Psst! Wanna buy some drugs?

• Ginkgo Biloba 120 mg/day
• acetylcholinesterase inhibitor
• anti-oxidant
• Vitamin E 2000 IU?
• Melatonin Aricept study
• Upcoming

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Any other suggestions?

• Anti-inflammatories
• Estrogen
• Prevention
• Genetic testing

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Any other suggestions?

• Patient/family support
• Alzheimers Society and Wandering Registry
• Respite
• Home Care
• CARE program
• regular office visits
• Planning
• competence
• driving
• POA/advance directives
• placement

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How do you quickly sort out delirium vs dementia?

• Key Questions
• Are the changes abrupt or over a long period?
• Is the Level of Consciousness impaired?
• Are there hallucinations?
• Are there physical signs present?

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In Summary . . .

• Sort out
• delirium vs dementia
• reversible vs non-reversible
• Treat what can be treated
• Support for patient family

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Infectious agents -HSV1 - chlamydia pneumoniae
free radicals
Aging apoptosis
?
?
?
Pathological Cascade in Alzheimers Disease
Inflammation -activation of microglia, astrocytes
Neurotransmitter failures
?
?
?
?
?
amyloid plaques neurofibrillary tangles
Genetics FAD early onset - chrom 1,14 FAD late
onset -chromc 12,21 APOE4-chrom19 ?other genes
Low education
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Delirium Dementia
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ALGORITHM FOR THE DIAGNOSIS OF DEMENTIA
Complaints of memory loss
Caregiver confirms Decline in function Objective
evidence of cognitive decline
NO
YES
Suspect dementia
Subjective complaints
NO
YES
NO
YES
Symptoms may be the result of depression or
anxiety. Re-evaluation in 3-6 months.
Take history of illness from patient and reliable
information, including Onset of symptoms
duration of symptomsevolution of symptoms
precipitating factors family history
Conduct physical examinations Conduct mental
functional assessment ( e.g.. MMSE
FAQ) Conduct laboratory tests (CBC, TSH,
electrolytes, calcium glucose) Conduct other
tests as indicated (CT or MRI in specific cases)
Eliminate presence of reversible conditions -
substance abuse adverse drug effects
depression metabolic
disorders systemic illness.
YES
Treat these causes
Are there other causes for the symptoms?
Diagnosis of dementia confirmed
NO