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Delirium and Dementia

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Title: PowerPoint Presentation Author: library3 Last modified by: James Czarnecki Created Date: 10/5/2004 10:51:36 PM Document presentation format – PowerPoint PPT presentation

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Title: Delirium and Dementia


1
Delirium and Dementia
  • A Brief Overview and Differentiation
  • Of These Clinical Entities

2
Differences
  • Delirium
  • Develops rapidly
  • Fluctuating course
  • Potentially reversible
  • Profoundly affects attention
  • Requires emergent investigation of underlying
    cause and treatment
  • Dementia
  • Develops slowly
  • Slow progressive course
  • Not reversible
  • Profoundly affects memory
  • Nonemergent evaluation and treatment

3
Differences
  • Both delirium and dementia represent states of
    cognitive impairment and dysfunction.

4
Differences
  • Hypothyroidism can progress to a progressive
    state resembling dementia clinically, however is
    generally reversible with treatment. All patients
    seen in the office who begin to appear to be
    showing some signs of dementia should be screened
    for thyroid illness for this reason.

5
Delirium
  • An acute confusional state
  • Fluctuating disturbances in
  • cognition
  • mood
  • attention
  • arousal
  • self awareness

6
Delirium
  • Disorientation can be rapidly fluctuating and
    accompanied by diminished level of consciousness
  • Many authors propose slightly varied
    definitions/descriptions but there is a general
    consensus that ability to pay attention to
    surrounds (attentiveness) is poor.

7
Delirium
  • Changes in personality and affect are common
  • Full medical workup is ncessary to distinguish
    the two (delirium vs dementia)
  • Treatment of delirium is directly aimed at
    underlying cause and psychoactive medications
    have a limited role.

8
Delirium
  • Etiology can be divided into four general
    categories
  • Metabolic
  • Toxic (Medication)
  • Infectious
  • Structural

9
Delirium Metabolic Causes
  • Hypoxia
  • Thyroid disorder
  • Metabolic or Respiratory acidosis (hypercapnea)
  • Hypoglycemia or severe hyperglycemia
  • Hypercalcemia
  • Potassium imbalance, sodium imbalance (common in
    elderly)
  • Post-ictal state or transient ischemic state

10
Delirium - Drugs
  • Anticholinergices
  • TCAs
  • Antiemetics
  • Older generation antihistamines
  • Muscle relaxants
  • CNS depressants (benzos narcotics, and
    psychotics)

11
Delirium Drugs continued
  • Cimetidine
  • Withdrawal of substances and medications is also
    an important consideration (alcohol,
    benzodiazepines)

12
Delirium Infectious Causes
  • Acute CNS infections
  • Systemic infections
  • Remote infections
  • Fever itself will cause a delirium
  • Pneumonia (frequent culprit in elderly)
  • UTIs (frequent culprit in elderly)

13
Delirium - Structural
  • Any structural abnormality in the brain can cause
    delirium
  • Acute CVA
  • Tumor
  • Abscess

14
Delirium Structural
  • Many physicians will argue that CT and MRI are
    imperative, however such defects will produce
    lateralizing signs on clinical exam, and if
    imaging is not correlated with findings at
    bedside, utility of this testing is limited.

15
Delirium - Workup
  • CBC
  • BMP or CMP
  • Ammonia Level
  • Urinalysis with culture and sensitivity
  • Blood cultures
  • Chest x-ray
  • Toxicology screen if indicated

16
Delirium Workup
  • Vitamin B12 if CBC suggests longstanding
    deficiency
  • CT of the head
  • EEG
  • MRI if clinical exam and history warrants

17
Delirium - Workup
  • VDRL if history of syphyllis
  • Lumbar puncture if indicated
  • Culture
  • Gram stain
  • Cell count
  • Total protein
  • Glucose

18
Delirium Workup
  • Thyroid studies are controversial in acutely ill
    patients, usually reserved for suspicion of
    myxedema coma or acute thyroid storm.
  • Remember cognition deficits secondary to thyroid
    illness will typically progress slowly and mimic
    dementia.

19
Delirium - Treatment
  • Focused toward underlying cause.
  • ETOH withdrawal treated with benzodiazepine's and
    thiamine.
  • Medications need to be thoroughly reviewed.
  • Electrolyte/metabolic abnormalities corrected and
    infections treated appropriately.

20
Delirium - Treatment
  • Agitation in the hospital needs to be assessed in
    person by the physician. All efforts need to be
    made to orient the person to place and time.

21
Delirium - Treatment
  • Medication is considered a chemical restraint,
    needs to be administered judiciously, and must be
    thoroughly documented on the chart.

22
Delirium - Treatment
  • The American Geriatric Society estimates up to
    18 of hospitalized elderly patients with
    delirium die
  • Length of hospital stay is twice as long for
    those who develop confusion during
    hospitalization
  • Try to avoid writing for routine PRN sedatives on
    the elderly for agitation. Acute mental status
    changes need to be assessed.

23
Dementia
  • Chronic deterioration of memory, especially short
    term
  • Intellectually function eventually severe enough
    to interfere with ability to perform Activities
    of Daily Living
  • Mostly a disease of the elderly
  • Affects young people primarily as a result of
    injury or prolonged hypoxia.

24
Dementia - Prevalence
  • 1 to 2 in people lt 65
  • 5 to 15 in people gt 65
  • 30 to 50 in people gt 80
  • Prevalence increases rapidly with age.
  • It accounts for more than 50 of nursing home
    admissions. Its prevalence in Nursing home
    population is estimated to be 60 to 80.

25
Dementia
  • In general, it is a condition most feared by the
    aging adults.
  • Dementia predisposes oneself to delirium. A
    diagnosis of Dementia cannot be made while a
    patient is delirious.

26
Dementia
  • Early dementia presents as short term memory loss
    and must be differentiated from benign senescent
    forgetfulness (age related memory loss). Given
    extra time for recall, these individuals do not
    show much change in intellectual performance.
    These individuals are often more concerned about
    their mental status than family members,
    typically the reverse of that observed in
    dementia.

27
Dementia - Early
  • Early dementia, with its short term memory loss
    often results in forgetting where they placed
    certain belongings. This can lead to some
    paranoia (often patients in nursing homes will
    insist that people are stealing from them).

28
Dementia - Intermediate
  • Intermediate dementia shows the ability to
    perform ADLs actually declines. Significant
    paranoia is seen in 25 of patients.
  • Wandering is a significant problem.
  • A poignant delusion/paranoia that has been
    described is the inability of the individual to
    recognize themselves in a mirror, leading to
    suspicion that a stranger has entered their home.

29
Dementia - Severe
  • Severe dementia results in complete dependence on
    others for essential ADLs. Long term memory also
    becomes lost. Family members are not recognized.
  • The natural course of death in individuals who
    progress to severe dementia is often due to
    bacterial infection.

30
Dementia - Classification
  • Primary dementia (cortical dementia)
  • Alzheimers disease
  • Picks disease
  • Frontal lobe dementia syndromes
  • Mixed dementia with Alzheimers component

31
Dementia - Classification
  • Vascular Dementia
  • Multi-infarct dementia
  • Strategic infarct dementia
  • Lacunar state
  • Binswangers disease
  • Mixed vascular dementia

32
Dementia Lewy Body
  • Dementia associated with Lewy Body Disease
  • Parkinsons-associated dementia
  • Progressive supranuclear palsy
  • Diffuse Lewy body disease

33
Dementia - Toxicity
  • Dementia due to toxic ingestion
  • Alcohol-associated dementia
  • Dementia due to heavy metal or other toxin
    exposures

34
Dementia - Infection
  • Dementia due to infection
  • Viral HIV_associated dementia, postencephalitis
    syndromes
  • Spirochetal neurosyphilis, Lyme disease
  • Prion Creutzfeldt-Jakob disease

35
Dementia - Structural
  • Dementia due to structural brain abnormalities
  • Norma-pressure hydrocephalus
  • Chronic subdural hematomas
  • Brain tumors

36
Dementia - Reversible
  • Some potentially reversible conditions mimicking
    dementia
  • Hypothyroidism
  • Depression
  • Vitamin B12 deficiency

37
Dementia
  • Alzheimers disease is by far the most common
    type of dementia with accounting for
    approximately 65 to 70 of all diagnosed cases of
    dementia in the elderly.
  • Vascular etiology dementia are second most common
    accounting for approximately 20 of cases in the
    elderly.

38
Dementia - Treatment
  • Screening with mental status exams
  • If possible, family members should be interviewed
  • Rule out correctable factors (thyroid, B12
    deficiency)
  • Inquire about medication (including OTCs) and
    alcohol use

39
Dementia - Treatment
  • If possible eleminate all poten psychoactive
    drugs and repeat MMSE 4-6 weeks
  • Physical exam should screen for signs in
    self-care deficits
  • Brain imaging is controversial. Reversible
    abnormalities (mass lesions) should manifest with
    thorough physical exam.

40
Dementia - Treatment
  • Most common use of imaging has been to
    differentiate Alzheimers dementia from vascular
    dementia. CT is adequate in this case.
  • In several studies, the use of diagnostic imaging
    did not justify the cost in patients presenting
    with classic Alzheimers Dementia, as patient
    with vascular dementia already often have readily
    identifiable risk factors of HTN, hyperlipidemia,
    known carotid vessel disease, or known vascular
    disease.

41
Dementia - Treatments
  • Medications exist that are aimed at improving
    cognition in early stages of common forms of
    dementia
  • These function by inhibiting acetylcholinesterase
    in the CNS and for a short period of time slow
    progression of disease and in some patients can
    cause short term improvement in function.

42
Dementia - Treatments
  • Medications include
  • Aricept
  • Reminyl
  • Exelon
  • Cognex
  • Because they are potent cholinergic medications,
    one must limit anticholinergic medication use for
    full benefit, otherwise little benefit may be
    observed secondary to pharmacologic antagonism

43
Dementia - Treatments
  • Namenda (mamentadine) is a NMDA receptor agonist
    that shows promise in treatment of more
    progressive cases and can be utilized in
    conjunction with cholinesterase inhibitors.
  • SSRIs are recommended for treatment of
    depressive symptoms.
  • Depression occurs in up to 40 of patients with
    early dementia.

44
Dementia - Treatments
  • Support must be provided for family members and
    caregivers.
  • These individuals suffer a much higher rate of
    depression, especially as they reach their
    threshold for burnout.

45
Dementia - Treatments
  • End of life issues should be addressed early
  • There is no prognostic model for dementia, unlike
    other terminal conditions such as cancer
  • Rate of progression is unpredictable

46
Delirium Dementia
  • Questions?
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