Dementia and Delirium Overview
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Questions and Answers

What is a defining characteristic of dementia?

  • Presence of a single cognitive deficit
  • Sudden onset of cognitive impairment
  • Progressive decline in cognition including memory loss and another cognitive domain (correct)
  • Recovery of lost cognitive function

Which of the following is a common cause of dementia?

  • Acute stress disorder
  • Traumatic brain injury
  • Bipolar disorder
  • Alzheimer's disease (correct)

What finding is associated with Alzheimer's disease?

  • Presence of amyloid plaques and neurofibrillary tangles (correct)
  • Growth of new neurons in the hippocampus
  • Increase in cholinergic transmission
  • Elevated serotonin levels

Which group has the highest prevalence of dementia?

<p>Individuals over 90 years of age (A)</p> Signup and view all the answers

What is a significant downside to the traditional model of diagnosing Alzheimer's disease?

<p>Clinical diagnosis often lacks high sensitivity and specificity (B)</p> Signup and view all the answers

Which statement best describes the prognosis of vascular dementia?

<p>Associated with a prognosis of around 5 years (A)</p> Signup and view all the answers

Which cognitive domain is NOT required for a dementia diagnosis?

<p>Creativity (D)</p> Signup and view all the answers

What is a potential risk factor for developing delirium?

<p>Advanced age (D)</p> Signup and view all the answers

What is a key non-pharmacological strategy for managing patients?

<p>Educate family and caregivers (C)</p> Signup and view all the answers

Which of the following is a significant complication associated with delirium?

<p>Pressure sores (B)</p> Signup and view all the answers

What is the recommended approach for administering pharmacological treatment in patients with delirium?

<p>Start low and go slow (A)</p> Signup and view all the answers

What distinguishes delirium from dementia?

<p>Consciousness is usually altered in delirium. (D)</p> Signup and view all the answers

Which of these is not a potential long-term consequence of delirium?

<p>Permanent cognitive improvement (C)</p> Signup and view all the answers

Why should sedation be avoided unless absolutely necessary in delirious patients?

<p>It is associated with increased mortality rates. (A)</p> Signup and view all the answers

What is the typical duration of delirium symptoms?

<p>Days to weeks (D)</p> Signup and view all the answers

What is the prognosis for patients experiencing hypoactive delirium?

<p>Worse prognosis due to later diagnosis. (C)</p> Signup and view all the answers

What is the primary focus of the FINGER Study conducted in 2015?

<p>Impact of diet, social engagement, exercise, and medication on cognitive decline (C)</p> Signup and view all the answers

Which approach is emphasized for managing dementia according to the content?

<p>Multidisciplinary team approach including family support (C)</p> Signup and view all the answers

What lifestyle changes can help prevent damage to the brain and reduce dementia risk?

<p>Regular exercise and maintaining a healthy diet (B)</p> Signup and view all the answers

Which of the following medications is considered a cholinesterase inhibitor used in dementia treatment?

<p>Donepezil (A)</p> Signup and view all the answers

For preventing vascular dementia, which intervention is notably recommended for middle-aged and older adults?

<p>Active treatment of blood pressure (B)</p> Signup and view all the answers

What is an important aspect to consider in non-pharmacological management of dementia?

<p>Monitoring carer stress (D)</p> Signup and view all the answers

Which of the following options is not advised for managing dementia symptoms?

<p>Abusing alcohol (A)</p> Signup and view all the answers

In the case of the 80-year-old male with mild-moderate dementia, which medication would be the most appropriate for him?

<p>Donepezil (C)</p> Signup and view all the answers

What primarily causes vascular dementia?

<p>Reduced blood flow to the brain (D)</p> Signup and view all the answers

Which of the following symptoms is commonly associated with frontotemporal dementia?

<p>Altered personality and social behavior (D)</p> Signup and view all the answers

Which combination of symptoms defines Lewy body dementia?

<p>Visual hallucinations, fluctuating cognition, and Parkinsonism (C)</p> Signup and view all the answers

What is a common sign of delirium in a patient?

<p>Decreased activity and awareness (D)</p> Signup and view all the answers

Which of the following is NOT a risk factor for developing delirium?

<p>Increased physical exercise (C)</p> Signup and view all the answers

What does apraxia refer to in the context of dementia symptoms?

<p>Inability to complete motor tasks despite proficiency (B)</p> Signup and view all the answers

Which type of delirium involves heightened arousal and agitation?

<p>Hyperactive delirium (B)</p> Signup and view all the answers

What is a key aspect of diagnosing dementia during assessment?

<p>Identifying instrumental activities that become impaired (C)</p> Signup and view all the answers

Which substance is most likely to cause or worsen delirium?

<p>Analgesics, especially opioids (D)</p> Signup and view all the answers

Which of the following is a possible underlying cause of delirium?

<p>Unfamiliar environment (B)</p> Signup and view all the answers

What cognitive assessment tool is commonly used to measure cognition in potential dementia patients?

<p>MMSE (A)</p> Signup and view all the answers

Which condition is NOT typically included in the differential diagnosis for dementia?

<p>Asthma (A)</p> Signup and view all the answers

What is the relationship between frontotemporal dementia and genetics?

<p>1/3 of cases are inherited. (A)</p> Signup and view all the answers

Which of the following symptoms is indicative of delirium?

<p>Acute onset of disorientation (A)</p> Signup and view all the answers

What is the first line treatment for mild to moderate dementia?

<p>Donepezil (B)</p> Signup and view all the answers

Which type of dementia currently has no specific treatment available?

<p>Lewy body dementia (B)</p> Signup and view all the answers

What is a significant risk associated with the new disease-modifying treatments for Alzheimer’s disease?

<p>Amyloid related imaging abnormalities (ARIAs) (D)</p> Signup and view all the answers

Which of the following is a contraindication for the new disease-modifying treatments?

<p>APOE-4 positive status (B)</p> Signup and view all the answers

What investigation is considered the leading cause of delirium?

<p>Infection (D)</p> Signup and view all the answers

Which cognitive assessment tool is used to evaluate alertness, awareness, attention, and behavior changes?

<p>4AT (A)</p> Signup and view all the answers

Which type of biomarker is expected to become available for dementia diagnosis in the next 2-5 years?

<p>Brain-derived p-tau217 (A)</p> Signup and view all the answers

What is the primary management strategy for delirium?

<p>Avoidance of triggers (D)</p> Signup and view all the answers

What characteristic is essential in defining dementia?

<p>Decline in cognition affecting memory plus another cognitive domain (C)</p> Signup and view all the answers

Which of the following is associated with Alzheimer’s disease pathology?

<p>Development of neurofibrillary tangles (D)</p> Signup and view all the answers

Identifying dementia involves which investigative approach?

<p>Exclusion of dementia mimics and clinical history (C)</p> Signup and view all the answers

Which type of dementia is associated with the shortest life expectancy post-diagnosis?

<p>Lewy body dementia (A)</p> Signup and view all the answers

What factor significantly complicates the diagnosis of Alzheimer’s disease?

<p>Variation in clinician experience leading to diagnostic inconsistencies (C)</p> Signup and view all the answers

Which of the following types of dementia is linked with a genetic predisposition?

<p>Frontotemporal dementia (A)</p> Signup and view all the answers

What aspect of dementia significantly impacts its prevalence among older adults?

<p>Age-related cognitive decline (D)</p> Signup and view all the answers

Which condition is frequently excluded when diagnosing different types of dementia?

<p>Normal aging process (C)</p> Signup and view all the answers

What is a crucial element in the non-pharmacological management of delirium?

<p>Educating family and caregivers (C)</p> Signup and view all the answers

Which of the following pharmacological treatments should be avoided in patients with Parkinson's disease?

<p>Antipsychotics like Risperidone (C)</p> Signup and view all the answers

What is the expected prognosis for patients experiencing hypoactive delirium compared to other forms?

<p>Worse prognosis due to later diagnosis (A)</p> Signup and view all the answers

What complication is most specifically associated with prolonged delirium in older patients?

<p>Long term cognitive or functional impairment (D)</p> Signup and view all the answers

In the context of delirium management, what is the most appropriate approach to the use of sedatives?

<p>Reserve for patients at risk to themselves or others (B)</p> Signup and view all the answers

What is an important factor to monitor in patients with delirium to prevent complications?

<p>Fluid intake to prevent dehydration (D)</p> Signup and view all the answers

How does the onset of delirium typically differ from that of dementia?

<p>Delirium is characterized by an immediate onset within hours to days (B)</p> Signup and view all the answers

What is a significant long-term consequence of experiencing delirium in older adults?

<p>Increased risk of institutionalization and cognitive decline (C)</p> Signup and view all the answers

What is the potential impact of maintaining a cognitively enriching environment in adulthood on dementia risk?

<p>It may strengthen the brain and reduce dementia risk. (A)</p> Signup and view all the answers

Which pharmacological treatment would be the most suitable for an elderly patient experiencing mild-moderate dementia?

<p>Memantine (C)</p> Signup and view all the answers

In the context of preventing vascular dementia, which method is emphasized as effective for middle-aged and older adults?

<p>Active management of blood pressure (A)</p> Signup and view all the answers

Which statement best describes a significant recommendation made for non-pharmacological management of dementia?

<p>It should involve a multidisciplinary team approach. (C)</p> Signup and view all the answers

Which of the following is NOT recommended as a part of management strategies for dementia?

<p>Increasing alcohol intake (C)</p> Signup and view all the answers

What role does the FINGER Study highlight in reducing cognitive decline?

<p>A combination of diet, social engagement, and exercise is effective. (B)</p> Signup and view all the answers

What common misconception about dementia management is highlighted in the document?

<p>Pharmacological treatments are the only effective options. (A)</p> Signup and view all the answers

Why is monitoring carer stress considered important in dementia management?

<p>It can negatively impact the caregiver's health and the patient's care quality. (A)</p> Signup and view all the answers

What is the primary characteristic of drugs like Aducanemab and Lecanemab in the treatment of Alzheimer's disease?

<p>They target amyloid plaques in the brain. (A)</p> Signup and view all the answers

What is a potential drawback of new disease-modifying treatments such as Aducanemab?

<p>They carry risks of amyloid-related imaging abnormalities (ARIA). (A)</p> Signup and view all the answers

Which imaging technique is noted to be most effective for diagnosing dementia?

<p>Combined PET amyloid/FDG scans (C)</p> Signup and view all the answers

What factor is considered a relative contraindication for the new disease-modifying treatments in Alzheimer's disease?

<p>Having APOE-4 positive status (B)</p> Signup and view all the answers

Which medication is commonly utilized to manage agitation in patients with frontotemporal dementia?

<p>Agitation-reducing medications (D)</p> Signup and view all the answers

What is the main purpose for performing a lumbar puncture in the context of delirium suspected due to infection?

<p>To extract cerebrospinal fluid for analysis (D)</p> Signup and view all the answers

What is a significant development expected in dementia treatment that involves biomarkers?

<p>The availability of brain-derived p-tau217 as a serum biomarker. (D)</p> Signup and view all the answers

Which cognitive assessment tool evaluates multiple domains associated with alertness, awareness, attention, and behavior change?

<p>4AT (D)</p> Signup and view all the answers

What characterizes the progression of vascular dementia?

<p>Step-wise deterioration with periods of functional plateau (B)</p> Signup and view all the answers

Which symptom is most closely associated with frontotemporal dementia?

<p>Altered personality and social behavior (A)</p> Signup and view all the answers

Which of the following describes Lewy body dementia?

<p>Characterized by a specific triad of symptoms (A)</p> Signup and view all the answers

Which of the following conditions could be included in the differential diagnosis for dementia?

<p>Normal pressure hydrocephalus (C)</p> Signup and view all the answers

What are common symptoms of delirium?

<p>Acute disorientation and fluctuating mental status (C)</p> Signup and view all the answers

What type of cognitive assessment is the MMSE classified as?

<p>Bedside cognitive assessment (C)</p> Signup and view all the answers

Which of the following is a common risk factor that can increase the likelihood of developing delirium?

<p>Visual or hearing impairment (A)</p> Signup and view all the answers

Which variant of frontotemporal dementia involves language disturbances?

<p>Primary progressive aphasia (D)</p> Signup and view all the answers

Which of the following is NOT a common symptom of dementia?

<p>Acute disorientation only in time (C)</p> Signup and view all the answers

What is a significant expected outcome when using PET imaging in dementia diagnosis?

<p>Evaluation of brain metabolism and amyloid deposits (B)</p> Signup and view all the answers

Which cause is related to the development of delirium as indicated by the acronym 'DELIRIUM'?

<p>Environmental changes (A)</p> Signup and view all the answers

Which of the following statements is true about memory impairment in dementia?

<p>Memory impairment can occur alongside other cognitive decline (A)</p> Signup and view all the answers

Which of the following is a potential effect of delirium concerning patient behavior?

<p>Increased agitation and restlessness (B)</p> Signup and view all the answers

Flashcards

Dementia

A progressive condition causing cognitive decline, including memory loss and at least one other cognitive impairment (language, executive function, etc.).

Alzheimer's Disease

The most common type of dementia, characterized by the loss of brain cells involved in communication, leading to amyloid plaques and neurofibrillary tangles in the brain.

Causes of Dementia (Types)

Various conditions, including Alzheimer's Disease, vascular dementia, dementia with Lewy bodies, and other neurological diseases, contribute to dementia development.

Dementia Symptoms

Include memory loss and impairment in other cognitive areas like language, problem-solving, or judgment, significantly impacting daily life.

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Progressive Neurogenerative

Describing a disease process where the neurological tissue degrades or deteriorates over time, often resulting in cognitive decline.

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Prevalence of Dementia

Dementia becomes increasingly common with age, affecting approximately 4% of individuals over 65 years old and substantially higher rates in older age groups.

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Mixed Dementia

A type of dementia resulting from a combination of different types of contributing factors to dementia.

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Diagnosis of Alzheimer's

Diagnosis of Alzheimer's is typically based on a patient history, exclusion of mimicking conditions and neuroimaging to support a diagnosis of probable Alzheimer's.

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Pharmacological Management

Using medications to manage dementia symptoms and slow progression. Includes cholinesterase inhibitors like Donepezil and NMDA receptor antagonists like Memantine.

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Cholinesterase Inhibitors

Drugs like Donepezil, Rivastigmine, and Galantamine that increase acetylcholine levels in the brain, improving communication between brain cells.

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NMDA Receptor Antagonist

A drug like Memantine that blocks the NMDA receptor, reducing brain cell damage and improving cognitive function.

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Non-Pharmacological Management

Using non-medication approaches to manage dementia symptoms and improve quality of life. This includes multidisciplinary team support, family education, and driving assessments.

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Multidisciplinary Team

A group of professionals with different specialties working together to manage dementia. Includes occupational therapists, social workers, pharmacists, and more.

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Dementia Prevention

Steps taken to reduce the risk of developing dementia, including healthy lifestyle choices, managing blood pressure, and maintaining cognitive activity.

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FINGER Study

A landmark study showing that a combination of diet, social engagement, exercise, and medication can significantly reduce cognitive decline.

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Cognitive Decline

A gradual deterioration of mental abilities, including memory, thinking, and problem-solving, often a symptom of dementia.

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First-line Treatment for Mild to Moderate Dementia

Cholinesterase inhibitors are the initial choice for treating patients with mild to moderate dementia, particularly Alzheimer's disease.

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Treatment for Vascular Dementia

There is no specific treatment for vascular dementia, which is caused by damage to blood vessels in the brain.

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Aducanumab (Aduhelm)

A groundbreaking treatment for Alzheimer's disease that targets amyloid beta plaques in the brain.

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Amyloid-Related Imaging Abnormalities (ARIAs)

Potential side effects associated with amyloid-lowering treatments, including cerebral edema (swelling) and bleeding.

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Contraindication for Amyloid Lowering Treatments

Anticoagulation (blood thinners) is strongly discouraged for patients receiving amyloid-lowering treatments due to the risk of bleeding in the brain.

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Combined PET Amyloid/FDG

A powerful diagnostic tool using PET scans to assess both amyloid plaques and brain metabolism in dementia.

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Brain-Derived p-Tau217

A promising serum biomarker currently in development that may help diagnose Alzheimer's disease earlier.

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Vascular Dementia

Dementia caused by reduced blood flow to the brain, often from multiple small strokes.

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Frontotemporal Dementia

Progressive brain damage in frontal and temporal lobes, affecting personality, behavior, and language.

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Lewy Body Dementia

Dementia featuring visual hallucinations, fluctuating cognition, and Parkinsonian symptoms.

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Delirium

Acute, fluctuating change in mental status, marked by disorientation, short-term memory loss, and altered consciousness.

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Delirium Causes

Various factors like infections, medications, dehydration, and metabolic issues can cause delirium.

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Dementia Diagnosis

Involves patient history, physical exam, neuroimaging, cognitive testing, and ruling out other conditions.

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Dementia Prognostic Markers

Weight loss, dependence on daily care, and infections are common indicators of reduced functioning in dementia patients.

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Delirium Symptoms

Sudden mental confusion, disorientation, impaired thinking, and fluctuating consciousness are symptoms.

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Differential Diagnosis

Differentiating dementia from other conditions like depression, metabolic issues, or drug effects.

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MMSE

Mini-Mental State Examination - a quick cognitive assessment tool.

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MOCA

Montreal Cognitive Assessment - a more comprehensive cognitive assessment tool.

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Neuroimaging

Brain scans (CT and MRI) to visualize brain structure and detect abnormalities.

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Delirium Signs

May include disorientation, altered consciousness, inappropriate behaviors, and difficulty with attention during general inspection.

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Risk Factors for Delirium

Increased age, physical weakness, existing dementia or stroke, disturbed sleep are among the factors.

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Hypoactive Delirium

A type of delirium where the patient is less active, withdrawn, and seems sluggish. They may appear sleepy, confused, and have difficulty concentrating.

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Delirium Risk Factors

Conditions that increase the likelihood of developing delirium, including advanced age, dementia, severe illness, surgery, medications, and dehydration.

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Delirium Complications

Negative consequences of delirium, such as increased risk of falls, pressure sores, infections, and long-term cognitive impairment.

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Delirium Treatment: NON-PHARMACOLOGICAL

Focuses on creating a safe and supportive environment by managing the patient's physical surroundings, reorienting them, encouraging early mobilization, and providing emotional support.

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Delirium Treatment: PHARMACOLOGICAL

Involves medications like antipsychotics and benzodiazepines, used for agitated and potentially dangerous patients, but with careful consideration due to potential risks and side effects.

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Delirium vs. Dementia

Delirium is a sudden and reversible state of confusion, while dementia is a progressive and irreversible decline in cognitive abilities.

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Delirium Prognosis

Delirium can have a significant impact on health, increasing the risk of death and long-term cognitive problems. Hypoactive delirium has a poorer prognosis than hyperactive delirium.

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What is dementia?

Dementia is a progressive brain disorder that gradually worsens, causing memory loss and other cognitive problems. It affects daily activities and independence.

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What are the main types of dementia?

Alzheimer's disease is the most common, followed by vascular dementia (related to blood vessel damage), Lewy body dementia (with Parkinson's-like features), and frontotemporal dementia (affecting personality and language).

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What happens in Alzheimer's disease?

Alzheimer's disease involves the loss of brain cells crucial for communication. This leads to the formation of amyloid plaques and neurofibrillary tangles, causing brain atrophy.

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How common is dementia?

Dementia is highly age-related. It affects about 4% of people over 65, increasing to 20% for those over 80 and a staggering 50% for individuals over 90.

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What is delirium?

Delirium is a sudden, temporary state of confusion, often characterized by disorientation, impaired thinking, and fluctuating awareness.

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What causes delirium?

Delirium can be triggered by infections, medications, dehydration, metabolic issues, and even surgery. It's often related to a medical illness or change in the body.

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How is dementia diagnosed?

A doctor will consider patient history, physical exams, neuroimaging, and cognitive tests. They also rule out other conditions that can mimic dementia.

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How is delirium treated?

Treatment focuses on managing the underlying cause. This may involve medication (for agitation) or supportive measures like hydration, reorientation, and a calm environment.

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What is the most appropriate treatment for mild-moderate dementia?

Donepezil is a cholinesterase inhibitor, a class of medications used to treat mild to moderate Alzheimer's disease.

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What are the main goals of dementia management?

Dementia management aims to delay or prevent cognitive decline, treat underlying medical conditions, and improve quality of life for those with dementia.

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What is the FINGER study?

The FINGER study showed that a combination of diet, social engagement, exercise, and medication can significantly reduce cognitive decline over two years.

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Multidisciplinary team approach

A team of healthcare professionals, including doctors, nurses, social workers, therapists, and pharmacists, working together to manage dementia.

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Delirium Onset

Delirium starts suddenly, within hours or days.

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Dementia Onset

Dementia develops gradually, over months or years.

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Dementia Course

Dementia symptoms worsen progressively over time.

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Delirium Reversibility

Delirium is usually reversible if the underlying cause is treated.

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Dementia Reversibility

Dementia is irreversible, the brain damage is permanent.

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Cholinesterase Inhibitors for Dementia

Drugs like Donepezil are the first-line treatment for mild to moderate dementia, especially Alzheimer's. They boost communication between brain cells by increasing acetylcholine levels.

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What are Aducanemab and Lecanemab?

These are new, biological drugs for Alzheimer's that target amyloid plaques in the brain. Lecanemab has fewer side effects and clears amyloid faster.

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Risks of Amyloid Lowering Treatments

These treatments can cause Amyloid Related Imaging Abnormalities (ARIAs), including cerebral edema (swelling) and bleeding. Anticoagulation is contraindicated.

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Combined PET Amyloid/FDG in Diagnosis

This powerful imaging test uses PET scans to check for amyloid plaques and brain metabolism, helping diagnose dementia, particularly Alzheimer's.

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Serum Biomarker for Alzheimer's

Brain-derived p-tau217 is a promising blood test in development that could help diagnose Alzheimer's earlier.

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Key Investigations for Delirium

Blood tests, cultures, CXR, urine dips, CT brain, EKG, and LP are used to rule out infections, electrolyte imbalances, hypoxia, and other sources of delirium.

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Management of Delirium

Preventing triggers, managing risk factors, and addressing the underlying cause of delirium are crucial.

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What is Vascular Dementia?

A type of dementia caused by reduced blood flow to the brain, often due to small strokes, leading to step-wise cognitive decline.

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What are the main characteristics of Frontotemporal Dementia?

Progressive degeneration of the frontal and temporal lobes affecting decision-making, behavior, emotions, and language.

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What are the key features of Lewy Body Dementia?

A type of dementia characterized by a triad of visual hallucinations, fluctuating cognition, and Parkinsonian symptoms.

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What are the main symptoms of Dementia?

Memory loss, language difficulties, difficulty recognizing faces or objects, impaired motor skills, disorientation, sleep changes, withdrawal, personality changes, and loss of independence.

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What are important Prognostic Markers of Dementia?

Weight loss, dependence on personal care, urinary tract infections, respiratory infections, and swallowing problems.

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What are the main types of Delirium?

Hyperactive: agitation, restlessness, hallucinations; Hypoactive: lethargy, lack of interest, reduced activity; Mixed: combination of both.

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What are the causes of Delirium?

Drugs, dehydration, electrolyte imbalance, infection, lack of sleep, restricted mobility, metabolic issues, and unfamiliar environment.

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What drugs can cause or worsen Delirium?

Analgesics (especially opioids), alcohol, anxiolytics, anticholinergics, anti-epileptics, psychotropics, antihistamines, steroids.

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What are the Risk Factors for developing Delirium?

Increased age, physical frailty, preexisting dementia, disturbed sleep, infection, trauma, sensory impairment, immobility, previous history of delirium, and drug use.

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What are the common symptoms of Delirium?

Sudden onset, disorientation, disordered thinking, fluctuating course, agitation, decreased activity, reduced speech, behavioral changes, and symptoms related to the underlying cause.

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What are some important signs of Delirium?

Disoriented in time and place, inappropriate dress, altered consciousness, repetitive behaviors, poor eye contact, inattention, slurred speech, and slow or reduced speech.

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What are the overarching principles to diagnose Dementia?

History (including collateral information), Examination, Neuroimaging, Cognitive Assessments, and exclusion of other conditions that mimic dementia.

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What are key historical questions to ask during a dementia assessment?

Difficulty with daily tasks (finances, travel), repetitive forgetting, word finding difficulties, safety issues, social withdrawal, apathy, weight loss, driving problems, and personality changes including delusions.

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What are some tools to measure cognition in Dementia?

Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MOCA), RUDAS, Addenbrooke's Cognitive Examination (ACE III).

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What investigations are helpful to diagnose Dementia?

Neuroimaging (CT, MRI), B12/folate levels, thyroid tests, and routine blood tests. PET scans and lumbar puncture are sometimes considered.

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Study Notes

Dementia and Delirium Overview

  • Dementia is a progressive neurodegenerative condition causing cognitive decline, including memory loss and at least one other cognitive domain impairment (language, executive, perceptual, social cognition).
  • Dementia impacts daily function and independence significantly.
  • Dementia is age-related, with prevalence increasing with age (4% over 65, 20% over 80, 50% over 90).
  • Dementia is common and often unrecognized in earlier stages.
  • Alzheimer's disease is the most common type (50-75%).
  • Vascular dementia accounts for 20-30% of cases.
  • Lewy body dementia accounts for 10-25% of cases.
  • Frontotemporal dementia makes up 10-15%.
  • Mixed dementia is also possible.

Learning Outcomes

  • Learning Outcome 1: Define Dementia.
  • Learning Outcome 2: List the causes/types of dementia.
  • Learning Outcome 3: Describe how each cause leads to the development of dementia.
  • Learning Outcome 4: Outline the common symptoms and signs of dementia.
  • Learning Outcome 5: Develop a differential diagnosis for Dementia - Consider other conditions which may cause similar symptoms.
  • Learning Outcome 6: Define Delirium.
  • Learning Outcome 7: List the causes/risk factors to develop Delirium.
  • Learning Outcome 8: Outline the common symptoms and signs in Delirium.
  • Learning Outcome 9: Outline the overarching principles of investigation and management of Dementia and Delirium.

Alzheimer's Disease (AD)

  • AD is the most frequent type of dementia characterized by cholinergic neuron loss, amyloid plaques, neurofibrillary tangles, and brain atrophy, especially in the hippocampus, with ventricular enlargement.
  • The APOE4 gene increases risk but only by 7%.
  • Progression is typically linear, declining over months to years.
  • AD is significant due to high prevalence and rising care costs - comparable to other serious illnesses.
  • Traditional diagnosis relies on informant history, normal neuro-imaging and excluding dementia mimics.
  • Formal diagnosis is using NINDS-ADRDA criteria.

Other Types of Dementia

  • Dementia associated with Parkinson's disease
  • Huntington's disease
  • Alcohol-related dementia
  • Progressive supranuclear palsy
  • Multiple systems atrophy
  • Creutzfeldt-Jakob disease
  • HIV-related cognitive impairment
  • Mixed dementia

Dementia Prognosis

  • Dementia is a progressive condition associated with morbidity and mortality.
  • Alzheimer's disease typically lasts 10 years.
  • Vascular dementia averages 5 years.
  • Lewy body dementia lasts approximately 2-8 years.

Dementia Symptoms

  • Forgetfulness, losing objects, forgetting appointments
  • Inability to follow movies/TV, inability to read books (amnesia)
  • Word-finding difficulties (aphasia/dysphasia)
  • Difficulty remembering familiar faces/items (agnosia)
  • Inability to complete motor tasks (apraxia)
  • Disorientation in time and place
  • Changes in sleep patterns
  • Withdrawal and apathy
  • Behavioral changes/personality changes/agitation and emotional lability
  • Loss of independence

Alzheimer's: DSM-IV Criteria

  • Development of multiple cognitive deficits demonstrating both memory impairment and one or more of the following: aphasia, apraxia (inability to perform learned purposeful movements), agnosia, and disturbance in executive function.
  • These deficits cause significant social or occupational impairments and represent a decline.
  • Onset is gradual.

Dementia Signs - General Inspection

  • Disorientation in time and place.
  • Sloppy dress and apathetic behavior
  • Visual hallucinations
  • Repetitive physical or behavioral disturbances
  • Tremor
  • Poor eye contact/affect incongruent with situation

Dementia Signs - Clinical Exam

  • Visual field deficits
  • Swallowing difficulty
  • Slurred speech and paucity of speech
  • Slow shuffling gait
  • Balance issues
  • Hemiparesis/spasticity with increased tone
  • Asymmetrical deep tendon reflexes
  • Changes in sensation

Prognostic Markers for Dementia

  • Weight loss
  • Functional loss/personal care dependence
  • UTI/LRTI if dependent or in a nursing home (NH) resident
  • Swallow impairment

Delirium

  • An acute, fluctuating change in mental status.
  • Associated symptoms include disorientation in time and place, impaired short-term memory, and altered level of consciousness.
  • Types: hyperactive (heightened arousal, restlessness, agitation, hallucinations), hypoactive (lethargy, lack of interest, reduced motor activity), and mixed (combination of both).

Causes of Delirium

  • Drugs (withdrawal, discomfort)
  • Electrolyte abnormalities
  • Environmental factors
  • Elimination problems
  • Lung problems (hypoxia)
  • Infection (iatrogenic events and or infarcions)
  • Renal failure
  • Restricted mobility
  • Injury or post-operative events
  • Impaired hearing/vision
  • Intoxication
  • UTIs
  • Unfamiliar environment
  • Metabolic abnormalities (e.g., glucose/thyroid)

Drugs Causing or Worsening Delirium

  • Analgesics (especially opioids)
  • Alcohol
  • Anxiolytics
  • Anticholinergics
  • Antiepileptics
  • Psychotropics
  • Antihistamines
  • Steroids

Risk Factors for Delirium

  • Increased age
  • Physical frailty
  • Existing dementia, stroke, Parkinson's disease
  • Disturbed sleep
  • Infection
  • Trauma
  • Visual or hearing impairment
  • Immobility
  • Previous history of delirium)
  • Polypharmacy, new medication, withdrawal, or toxicity

Delirium Symptoms

  • Acute onset
  • Disorientation in time and place
  • Disordered thinking
  • Sharply fluctuating course
  • Agitated and restless (increased wandering)
  • Decreased awareness and activity of surroundings
  • Decreased activity and speech
  • Behavioral disturbances and emotional lability
  • Symptoms suggestive of underlying aetiology

Delirium Signs

  • Possible disorientation in time and place
  • Sloppy dress or apathetic behavior
  • Altered consciousness/loss of awareness
  • Repetitive physical or behavioral disturbances
  • Poor eye contact/affect
  • Inattention
  • Slurred speech
  • Slow or absent speech

Dementia Diagnosis

  • History (collateral/informant history)
  • Examination/Neuro-imaging.
  • Bedside cognitive assessments
  • Exclude any dementia mimics.

Key Historical Questions for First Assessment (Dementia)

  • Instrumental activities become impaired (appointments, finances, travel, mobile phone, etc.)
  • Repetitive/rapid forgetting
  • Circumlocution/word finding difficulties
  • Safety issues (becoming lost, falls, kitchen accidents)
  • Withdrawal from social activity
  • Apathy
  • Weight loss/reduced dietary intake
  • Driving difficulty
  • Personality changes including delusions

Measuring Cognition

  • MMSE
  • MOCA
  • RUDAS
  • Addenbrookes' Cognitive Examination (ACE III)

Dementia Investigations

  • Neuroimaging (CT and MRI brain) - check for atrophy or structural issues
  • B12/folate, TFTs, routine bloods
  • SPECT/FDG/PET CT imaging (if diagnosis is unclear)
  • Lumbar puncture (not routinely done, can be helpful for younger patients)

New Diagnostic Tools

  • PET 18 FDG & PET amyloid scanning
  • PET Tau (research tool)
  • Tau serum biomarkers (being used in clinical trials, but lacking FDA approval)

Dementia Management - Non-Pharmacological

  • Multidisciplinary team approach
  • Caregiver and family support/education
  • Driving assessment
  • Discuss advance care directives (power of attorney)
  • Home supports as needed
  • Monitor caregiver stress

Dementia Management – Multidisciplinary

  • Occupational therapy (OT)
  • Medical social work
  • Pharmacist
  • Physiotherapist
  • Dietitian
  • Nursing
  • Neuropsychology (mental capacity)

Dementia Management - Pharmacological

  • Remove or minimize agents that impair cognition (anticholinergic Rx).
  • Cholinesterase inhibitors (Donepezil, rivastigmine, galantamine)
  • NMDA receptor antagonist (Memantine)
  • Manage hypertension
  • Avoid alcohol

Dementia Complications

  • Increased risk of falls and fractures
  • Immobility
  • Prolonged hospital stay
  • Pressure sores (hypoactive delirium)
  • Aspiration pneumonia and other infections.
  • Over sedation
  • Dehydration and malnutrition
  • Incontinence
  • Long-term cognitive impairment or functional decline (possible "new baseline")

Delirium Prognosis

  • Hypoactive delirium has a worse prognosis (often diagnosis is delayed) and response to treatment is typically slower.
  • Delirium can last for weeks or even months.
  • Delirium significantly impacts the health of older individuals.
  • Delirium increases risk of longer hospital stays.
  • Delirium increases the likelihood of long-term or permanent cognitive impairment, such as "new baseline" cognitive ability.
  • Delirium increases risk of institutionalization.
  • Delirium increases mortality risk (up to 22% mortality in six months).

Delirium Investigations

  • Cognitive assessments (4AT)
  • Bloods, blood gases, cultures, toxicology
  • Infection-related causes (e.g., CXR, urine dip)
  • Structural issues (e.g., CT brain)
  • MI or other precipitants (e.g., ECG)
  • CNS infection (e.g., lumbar puncture (LP))

Delirium Management - Non-Pharmacological

  • Avoid triggering factors; monitor risk factors
  • Treat underlying causes
  • Patient-centered care:
    • Nurse in well-lit, familiar rooms (ideally with same staff)
    • Educate families, caregivers.
    • Re-orient the patient.
    • Normalize sleep patterns (consider moving to side room).
    • Encourage mobility and self-care.
    • Avoid physical restraints; avoid urinary catheters/IVCs.
    • Monitor for dehydration, constipation, and pain.

Delirium Management - Pharmacological

  • Avoid sedatives (if possible)
  • Medications should be used cautiously in patients with agitation and aggression.
  • Start low and titrate slowly (begin with low-dose and adjust as required).
  • Antipsychotics (Risperidone or Olanzapine) – avoid in patients with Parkinson's Disease.
  • Short-acting benzodiazepines (e.g., Lorazepam)

New Disease-Modifying Treatments for Dementia

  • Aducanumab (Aduhelm)
  • Lecanemab (Leqembi) - reduced adverse reactions and faster amyloid clearance
  • Donanemab (not yet licensed)
  • Biological agents (humanized IgG monoclonal antibodies)
  • Targeting soluble and insoluble oligomers
  • Donanemab targeting pyroglutamate modification of A beta amyloid in plaques

Disease-Modifying Treatments for Alzheimer's (DMARDS)

  • Infusion therapies have shown benefits.
  • Significant Benefits may be offset by risks, including ARIAs (Amyloid-Related Imaging Abnormalities), Cerebral edema, and Cerebral hemorrhage.
  • FDA now specifies contraindications, such as anticoagulation and pre-existing microhemorrhages in certain patient populations (with positive APOE-E4 genotype or pre-existing microhemorrhages).

Dementia vs. Delirium

Provides a comparison table that differentiates the diagnoses of dementia and delirium.

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Related Documents

Dementia and Delirium Lecture PDF

Description

This quiz explores the key concepts surrounding dementia and its various types, including Alzheimer's and vascular dementia. It covers definitions, causes, symptoms, and the impact of dementia on daily life. Test your knowledge and understanding of this important public health issue.

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