Delirium, Depression and Dementia

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Delirium, Depression and Dementia

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Contents

• Clinical feature and diagnosis
• Delirium
• Depression
• Dementia
• Differential diagnosis of DDD

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Delirium

• ??????? acute, transient organic mental
  syndrome characterized by a global disorder of
  cognition and attention, a reduced level of
  consciousness, abnormality increased or reduced
  psychomotor activity, and a disturbed sleep wake
  cycle

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• third day post-op for
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PE T 36.5OC, BP 140/90 mmHg, P 96/min, R
16/min ????????????????? ??????????????????
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Dx ? Mx ?
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Diagnostic Criteria for Delirium
1 Disturbance of consciousness 2 A change in
cognition 3 Brief period and fluctuation
during the course of the day
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Diagnostic Criteria for Delirium
4 Caused by a. a general medical condition b. a
substance intoxication or side effect
c. a substance withdrawal d. multiple factors
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Disturbance of conscious alter in

• awareness
• alert
• attention

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• Disturbance in cognition
• What does it mean ?

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Cognitive function
- memory - perceiving - reasoning -
judgment - imagining - thinking
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Disturbance of cognition
1. Perceptual disturbance 2. Disorientation 3.
Memory disturbance
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Perceptual disturbance

• illusion
• delusion
• hallucination

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Abnormal of psychomotor activities
1. Hyperactive psychomotor activities 2.
Hypoactive psychomotor activities 3. Mixed type
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Factors Predisposing to Delirium

• Advance age
• Recent surgical procedure
• Trauma (including burns and hip
• fractures)
• Substance or drug use to dependence

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Factors Predisposing to Delirium

• Low serum albumin level
• Proteinuria

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Factors Predisposing to Delirium

• Medical condition
• CNS disease esp. dementia
• others are
• stroke
• seizure
• head injury
• metastasis to brain
• primary brain tumor

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Factors Predisposing to Delirium

• Cardiopulmonary problems eg.
• myocardial infarction
• congestive heart failure
• hypertensive encephalopathy
• pulmonary embolus
• pneumonia
• hypoxia from any cardiopulmonary
  condition

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Factors Predisposing to Delirium

• Metabolic disturbance eg.
• electrolyte abnormalities
• severe vitamin deficiency or malnutrition
• fluid imbalances
• hyperglycemia or hypoglycemia
• hyperthyroidism or hypothyroidism

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Factors Predisposing to Delirium

• Genitourinary problems
• uremia
• urinary tract infection
• severe urinary retention
• Infections potentially all infection

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Factors Predisposing to Delirium

• Gestrointestinal
• Hepatic encephalopathy
• Severe fecal impaction
• Rheumatologic
• Vasculitis

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Primary prevention of delirium in the elderly

• minimized drugs prescribed for the elderly
• avoid more than one drug with
• ant cholinergic effect
• identify who high risk for delirium

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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Cardio-vascular conditions Antiarrhythmics Antihypertensives Cardiac glycosides Coronary vasodilartors Procainamide, propranolol quinidine, Clonidine, methyldopa, reserpine Digitalis Nitrates
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Gastro-intestinal conditions Antidiarrheals Antinauseants Antispasmotics Atropine, belladonna, hyoscyamine, scopolamine Cimetidine, cyclizine, phenothiazines Methanthelene, propantheline
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Musculo-skeletal conditions Anti-inflammatory agents Muscle relaxants Corticosteroids, indomethacin, salicylates Carisoprodol, diazepam
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Neurologic- psychiatric conditions Anticonvulsants Antiparkinsonism agents Barbiturates, carbamazepine, diazepam, phenytoin Amantadine, benztropine, levopoda, trihexyphenidyl
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Neurologic- psychiatric conditions Hypnotics and sedatives Barbiturates, belladonna alkaloids, bromides, chloral hydrate, glutethimide Benzodiazepines,
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Neurologic- psychiatric conditions Psychotropics Benzodiazepines, hydroxyzines, lithium salts, meprobamate, monoamine oxidase inhibitors, neuroleptics, tricyclic antidepressants
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Respiratory-allergic conditions Antihistamines Brompheniramine, chlorpheniramine, cyproheptadine, diphenhydramine
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Respiratory-allergic conditions Antitussives Decongestants and expectorants Opiates, synthetic narcotics Phenylephrine, phenylpropanolamine, potassium preparations
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Miscellaneous conditions Analgesics Anaesthetics Dextropropoxyphene, opiates, phenacetin, salicylates, synthetic narcotics Lidocaine, methohexital, methoxyflurane
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Miscellaneous conditions Antidiabetic agents Antineoplastics Insulin, oral hypoglycemics Corticosteroids, mitomycin, procarbazine
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Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Miscellaneous conditions Antituberculosis agents Antibiotics Isoniazid, rifampin Ciprofloxacin, penicillin
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Depression

• Detinstion
• DSM-IV
• At least five of the following nine symptoms

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Depression

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• A depressed mood or lose of interest / pleasure
• Present most of the day, nearly everyday
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Depression

• Depressed mood
• Loss of interests / pleasure
• Change in sleep
• Change in appetite or weight
• Change in psychomotor activity

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Depression

• Loss of energy
• Trouble concentration
• Thoughts of worthlessness of guilt
• Thoughts about death or suicide

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Depression-defined

• sleep disturbances
• loss of interest
• feelings of guilt
• decreased energy

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Depression-defined

• concentration/memory problem
• appetite/weight changes
• psychomotor changes (agitation/retardation)
• thoughts of death or suicide

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Pharmacological Causes of Depression

• Cardiac and hypertensive drugs
• Reserpine , methyldopa , propanolol
• Sedatives and hypnotics
• Barbiturates , benzodiazepines
• Steroids and hormones
• Corticosteroid , estrogen , oral contraceptives

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Pharmacological Causes of Depression

• Psychotropic drugs
• Neurological agents
• Levodopa , amantadine
• Analgesics and anti-inflamatory drugs
• Antibacterial and antifungal drugs
• Antineoplastic drugs
• Vincristine , vinblastine

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Pharmacological Causes of Depression

• Stimulants and appetite suppressants
• amphetamine
• Miscellaneous drugs
• cimetidine

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Dementia
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Criteria for diagnosis of dementia (DSM IV)

• Development of multiple cognitive
• deficits including memory impairment
• and at least one of the following
• aphasia (deterioration in language)
• apraxia (impaired ability to execute
• motor abilities, sensory functions
• and comprehension of the task)

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Criteria for diagnosis of dementia (DSM IV)

• agnosia (failure to recognise and
• identify objects despite intact
• sensory functions)
• disturbance in executive functioning
• (ability to think abstractly, to plan,
• sequence, initiate, monitor and
• stop complex behaviour)

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Must be sufficiently severe to cause impairment
in occupation and social functioning, and
represent a decline from previous higher level
of functioning, should not be made during the
course of delirium
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Differential diagnosis of DDD

• Onset
• Clinical features
• Associated symptoms

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?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Onset Sudden Insidious Insidious
Course over 24 h Fluctuating, with nocturnal exacerbation Stable Stable
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?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Consciousness Reduced Clear Clear
Attention Globally disordered Normal, except in severe cases May be disordered
Cognition Globally disordered Globally impaired May be selectively impaired memory
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?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Hallucinations Usually visual or visual and auditory Often absent Often absent Except in psychotic depression-rare
Delusions Fleeting, poorly systematized Often absent Often absent
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?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Orientation Usually impaired, at least for a time Often impaired Normal
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?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Psychomotor activity Increased, reduced, or shifting unpredictably Often normal Varies from psychomotor retardation to hyperactivity depending on the type of depression
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?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Speech Often incoherent, show or rapid Patient has difficulty finding words perseveration Normal, show, or rapid
Involuntary movements Often asterixis or coarse tremor Often absent Usually absent, some fine tremor
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?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Physical illness or drug toxicity One or both are present Often absent, especially in senile dementia of the Alzheimer,s type Usually multiple complaints, poly pharmacy
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