Delirium and Dementia Summaries

• Summaries regarding delirium and dementia:

Delirium

• An acute and fluctuating disturbance of consciousness with associated cognitive changes indicate delirium
• It represents a physiological response to underlying medication or condition
• Infections, ischemic/hypoxic events, and metabolic disorders.

Delirium in the DSM-V

• The disturbance in attention and awareness develops over a short time, fluctuating during the day
• An additional disturbance in cognition
• It is not better explained by a pre-existing neurocognitive disorder, and doesn't exist during severely reduced arousal like coma
• There is evidence from history, physical exam, or labs showing the disturbance is a direct physiological consequence of another medical condition, substance intoxication/withdrawal, toxin exposure, or multiple etiologies

Confusion Assessment Method (CAM)

• Requires evidence of acute mental status change from baseline and fluctuating behavior during the day
• Inattention is when a patient has difficulty focusing and is easily distracted
• Disorganized thinking presents as speech that's disorganized or incoherent
• Altered consciousness levels include alert, vigilant, lethargic, stupor, and coma
• A delirium diagnosis requires present/abnormal ratings for criteria 1 and 2, along with either criteria 3 or 4

Delirium Epidemiology

• Delirium is associated with worse clinical outcomes
• Outcomes can include higher mortality, longer hospital stays, delayed/limited physical function recovery, and a greater probability of TCU placement
• Incidence rate during hospital admission after hip fracture is 28-61%
• Incidence rate during hospital admission after surgery is 15-53%
• Incidence rate during hospitalization for medical inpatients is 3-29%
• Prevalence in intensive care unit with mechanical ventilation is 60-80%
• Prevalence in intensive care unit without mechanical ventilation is 20-50%

Delirium Pathophysiology

• Main hypothesis is reversible impairment of cerebral oxidative metabolism and multiple neurotransmitter abnormalities
• Could be caused by neuroinflammation in acute systemic inflammation
• Could be caused by oxidative stress and hypoxemia
• Could be caused by neuronal aging and neuroendocrine dysregulation
• High glucocorticoid levels and circadian dysregulation impact delirium

Delirium Risk Factors

• Risk factors are categorized into predisposing factors and precipitating factors
• Cognitive impairment and severe illness
• Polypharmacy (accounts for about 30% of delirium etiology) and psychoactive medication use
• Sensory impairment and depression
• Alcoholism
• Predisposing factors: comorbidities, alcoholism, chronic pain, history of lung, liver, kidney, heart, or brain disease, terminal illness, age over 65, male sex, geriatric syndromes, dementia, depression, elder abuse, falls, history of delirium, malnutrition, polypharmacy, sensory impairment, premorbid state, inactivity, poor functional status, social isolation
• Precipitating factors: acute insults, dehydration, fracture, hypoxia, infection, ischemia (cerebral, cardiac), medications, metabolic derangement, poor nutrition, severe illness, shock, surgery, uncontrolled pain, urinary/stool retention, environmental exposures, intensive care unit setting, sleep deprivation, tethers
• High-risk medications: anticholinergics, benzodiazepines, dopamine agonists, meperidine

Delirium Clinical Presentation

• Clinical findings include hyperactive or hypoactive delirium
• Hyperactive: agitated elderly patients
• Hypoactive: new cognitive slowing or inattention
• Clouding of consciousness, difficulty maintaining/shifting attention, disorientation, illusions/hallucinations, and fluctuating consciousness levels

Delirium Work-Up

• Conduct a comprehensive review of medications, focused history, physical exam, basic lab studies (CBC, glucose, electrolytes, creatinine, BUN, calcium, urinalysis, pulse oximetry, EKG)
• If an offending drug is identified, discontinue it
• If trauma or focal finding, CT scan of the brain
• If infection is suspected, begin antibiotic therapy or perform a lumbar puncture
• Consider these labs if there is no obvious etiology: B12/folate levels, thyroid tests, EEG, MRI of brain
• Consider drug levels and toxin screen
• If the patient improves, discharge to appropriate post-acute setting
• If there is no improvement, reassess and consider prolonged delirium syndrome

Delirium Prevention

• Improve cognition through activities and socialization with family and friends
• Promote sleep through massage, noise reduction, and minimized interruptions
• Encourage mobility
• Provision of visual aids and hearing assistance
• Maintain hydration status
• Adaptive Equipment

Delirium Treatment

• Prevention
• Determine underlying cause and treat it
• Create a supportive and familiar environment
• Well-lit rooms, large clocks, familiar items, uninterrupted sleep, family nearby, and frequent staff checks
• Antipsychotics are used to treat symptomatically as necessary
• Example: Haloperidol, quetiapine, olanzapine, risperidone
• Benzodiazepines are only indicated for delirium caused by EtOH or benzo withdrawal

Dementia

• Represents acquired, sustained impairment in intellectual function with compromise in at least 3 specified mental activity spheres
• Memory, language, visuospatial skills, personality, and other cognitive abilities
• Diagnosis requires evidence of cognitive decline in cognitive domains
• Can be in learning and memory, language, executive function, complex attention, perceptual-motor, or social cognition
• Cognitive deficits interfere with independence in everyday activities and don't occur only in context of delirium
• Cognitive deficits aren't better explained by another mental health disorder
• Dementia affected 5.0 million Americans in 2014
• Up to 5 million more have a milder form of the dementia type
• It typically begins at age 60
• The main risk factor is age
• Other risks include family history, DM, nicotine, HTN, history of head injury, and hearing loss

Common Types of Dementia

• Alzheimer's disease
• Vascular dementia
• Dementia with Lewy bodies
• Frontotemporal dementia, including Pick disease
• Reversible causes (ex: normal-pressure hydrocephalus, thyroid dysfunction, vitamin B12 deficiency, depression)

Alzheimer Dementia

• Most common neurodegenerative diagnosis
• Early and prominent short-term memory impairment and typically a late onset
• Can have a rare early onset
• Sporadic or familial

Alzheimer Disease Pathophysiology

• Beta-amyloid plaques are related to abnormal protein processing, leading to plaque accumulation
• Plaques block cell signaling and activate immune responses, disabling cells
• Neurofibrillary tangles relates to accumulation of tau proteins
• AD tau is hyperphosphorylated, leading to tangles and neuron death

Vascular Dementia

• Stepwise progression due to multifocal ischemic changes
• Associated with repeated CVAs, symptoms correlate with stroke location, and often has vasculopathic risk factors

Dementia with Lewy Bodies

• Marked by cognitive/visuospatial dysfunction, psychiatric disturbances, and Parkinsonian motor changes
• Hallucinations and motor signs
• Delirium
• Caused by Lewy bodies, abnormal protein aggregations that develop inside nerve cells

Frontotemporal Dementia

• Defined by Bilateral frontal lobe atrophy with intraneuronal inclusions (Pick bodies)
• Prominent personality and behavioral changes
• Often misdiagnosed with psychiatric disorders
• Causes disturbances in behavior and conduct
• Loss of personal awareness and social comportment, disinhibition, impulsivity, distractibility, and hyperorality

Dementia Clinical Presentation

• Short-term memory loss
• Repetitive questions/stories, diminished recall of recent events
• Exhibit word-finding difficulty
• Impacts names of people, places, and low-frequency words
• Results in increased use of pronouns and circumlocutions
• Visuospatial dysfunction
• Poor navigation, getting lost, and loss of face/building recognition
• Executive dysfunction: distractibility, impulsivity
• Mental inflexibility, concrete thought, slowed processing, poor planning, impaired judgment
• Includes apathy and apraxia

Dementia Work-Up

• Complete neurological exam, rule out underlying etiologies, and screen for depression
• Used to detect mild impairment, but very insensitive
• Neuropsychiatric evaluations help to localize domains of impairment and quantify degree of impairment
• Conduct MRI/CT without contrast to r/o any new or progressive cognitive complaints
• r/o cerebrovascular dx, tumor, or structural abnormalities, but may not provide actual evidence of neurodegenerative disorders
• PET scans can differentiate Alzheimer's from frontotemporal dementia and provide evidence

Dementia Treatment

• Non-pharm treatments:
• Aerobic exercise, frequent mental and social stimulation and emphasize activities patient feels confident with
• Vitamin E and support groups for patients and families. prevention
• Encourage physical activity, provide intellectual stimulation, and encourage social engagement to increase cognitive reserve
• Cholinesterase inhibitors for AD and dementia with Lewy bodies
• Manage cognitive dysfunction and may prolong capacity for independence
• Does not prevent dx progression and not given for frontotemporal dementia (may worsen behavioral symptoms)
• NMDA receptor antagonists shouldn't be given for FTD and are only helpful in Lewy body dementia
• SSRIs (Citalopram) for depression, anxiety, and agitation
• Trazadone for insomnia
• Avoid triggers for agitation, impulsivity, and manage safety concerns
• Employing behavioral interventions and promoting daytime activity
• Atypical antipsychotics are only used when all other lifestyle changes remain ineffective

Delirium vs Dementia

• Delirium features an acute onset, fluctuating course, impaired awareness, and disturbed attention
• Memory is impaired with poor immediate recall and their delusions are short-lived and changing
• Sleep patterns are fragmented
• Dementia: insidious onset, gradual deterioration, awareness is clear until the late stages, attention is good until advanced, poor short term memory with fixed delusions, and a sleep-wake reversal

Explore summaries of delirium and dementia, covering key aspects such as diagnostic criteria and underlying causes. Delve into the differentiating characteristics of these conditions and their impact. Understand the methodologies and assessment tools used to diagnose delirium.