Delirium and Alzheimer's Overview

Delirium

• Delirium is an acute syndrome caused by a medical condition, substance, intoxication, or withdrawal, altering mental status temporarily.
• Examples include sepsis, sundowning, ETOH withdrawal, opiate withdrawal, and stroke.
• Common in hospitalized elderly patients, often caused by drugs, dehydration, infections (e.g., UTI), or other factors.
• Delirium is rapid in onset, short-term, and reversible.
• Criteria for diagnosis include:
  • Disturbed level of consciousness (decreased attention span, lack of awareness).
  • Cognitive changes (memory deficit, disorientation, language disturbance, possible visual illusions/hallucinations).
  • Rapid onset within hours or days, with a fluctuating course.
  • Evidence of a causal physical condition.
• Delirium is distinct from dementia, which is a long-term memory impairment, such as in Alzheimer's disease.

Alzheimer's Disease

• Alzheimer's disease is a progressive, neurodegenerative disease characterized by memory loss, language deterioration, impaired visuospatial skills, poor judgment, but preserved motor function.
• Begins after age 65.
• The most common cause of dementia.
• Acetylcholine is severely diminished in the brains of people with Alzheimer's, crucial for learning and memory.
• Cholinesterase inhibitors (e.g., donepezil, rivastigmine, galantamine) are established treatments, which aim to improve memory.
• Amyloid plaques (protein deposits) are a hallmark of Alzheimer's disease, found outside nerve cells.
• Avoiding haldol and anticholinergic drugs is important as these may worsen dementia.

Diagnosing/Evaluating Delirium/Alzheimer's

• History from family, caregivers, and friends along with mental status examination are critical to recognizing delirium.
• Thorough assessment for neurological and systemic causes/triggers.
• Testing may include CT/MRI, tests for infections (e.g., CBC, blood cultures, chest x-ray, urinalysis), electrolyte, BUN, creatinine, plasma glucose, drug levels, and urine drug screen (if indicated).
• Treat the underlying cause and provide supportive care, including sedation if needed.
• Mini-Mental Status Examination (MMSE) or Montreal Cognitive Assessment (MoCA) are screening tools, but neuropsychological testing may be necessary if history/bedside testing is inconclusive.
• Screen for depression, B12 deficiency, and hypothyroidism.
• Lumbar puncture considered if a chronic infection or neurosyphilis is suspected.
• Neuroimaging (MRI or CT) should be considered in the initial evaluation of all patients with dementia.

Managing Alzheimer's Disease

• Eliminate drugs with sedating or anticholinergic effects.
• Cholinesterase inhibitors (e.g., donepezil, rivastigmine, galantamine) can improve cognitive function.
• Memantine (NMDA antagonist) may slow cognitive decline in moderate-to-severe cases.
• Antipsychotics may be needed for behavior disorders, though nonanticholinergic antidepressants are preferred for depression.
• Maintaining safety is crucial, including measures to prevent falls and provide stimulating activities.
• Assist caregivers and make arrangements for end-of-life care.