Dementia and Delirium: Causes, Diagnosis & Treatment | PDF

Dementia and Delirium Dementia A disease process marked by progressive cognitive impairment Types: Alzheimer’s Frontotemporal Lewy Body Vascular Traumatic brain injury Substance -or-medication- induced Incidence The...

Dementia and Delirium Dementia A disease process marked by progressive cognitive impairment Types: Alzheimer’s Frontotemporal Lewy Body Vascular Traumatic brain injury Substance -or-medication- induced Incidence The World Health Organization estimates that 50 million people worldwide are affected by dementia Alzheimer’s type: accounts for 60-80% of dementia cases and is the leading cause of dementia worldwide Vascular: accounts for 20-30% of dementia cases, and its incidence increases linearly with age Lewy body disease: accounts for 10-25% of dementia cases Frontotemporal lobar degeneration (FTD): accounts for 10-15% of dementia cases. Among patients younger than 65, FTD accounts for 20-50% of dementia cases Etiology Dementia can be caused by a number of disorders: Alzheimer’s Vascular disease Frontotemporal lobar degeneration Lewy body disease Traumatic brain injury Substance/medication abuse HIV infection Prion disease Parkinson’s disease  Behavioral Disturbances Dementia may occur with or without behavioral disturbances; these disturbances may be unsafe or disruptive: Wandering Restlessness Agitation Aggression Sleep/wake cycle disturbances Apathy Difficulty Concentrating Delusions Hallucinations Diagnosis Requires a cognitive decline from a previous level of functioning in one or more domains: Complex attention Executive function Learning memory Language Perceptual motor Social Cognition The cognitive deficits must be severe enough to interfere with independence in everyday activities of daily living. Stages Early – Stage Middle - Stage Late- Stage Memory Loss Recent and remote memory Incontinence of urine and Time and spatial worsens feces disorientation Increased aphasia Loss of motor skills, rigidity Poor judgment Apraxia Decreased appetite and Withdrawal or depression Hyperorality dysphagia Perceptual disturbances Disorientation to place and Agnosia Apraxia time Restlessness or pacing Severely impaired Perseveration communication Possible inability to recognize Irritability Loss of impulse control family members or self in mirror Loss self-care abilities Severely impaired cognition  Risk factors Alzheimer’s disease ○ Age Lewy body disease ○ Family history of Alzheimer’s disease ○ Older than 60 years ○ Genetics ○ More common in men ○ Family history of Lewy body disease Vascular ○ Advanced age ○ History of heart attack, stroke or mini stroke Frontotemporal lobar ○ Atherosclerosis ○ High cholesterol degeneration ○ High blood pressure ○ Family history of dementia ○ Diabetes ○ Smoking ○ Obesity ○ Atrial Fibrillation  History: Focus should be on cognitive complaints and functional concerns, psychiatric and behavioral changes (the norm in dementia rather than the exception) Physical exam: May be generally normal except for neurological Assessment deficits may identify comorbid conditions that Findings contribute to cognitive dysfunction (hypothyroidism, postural hypotension, COPD, etc.) Cognitive exam: Used to develop differential list and to rate severity of dementia symptoms Mini Mental Status Examination-measures cognition; highly validated but limited in ability to measure cognition; highly validated but limited in ability to measure executive functions and memory impairment Differential Diagnosis Alcoholic Dementia Medication, organic toxin, heavy metal intoxication Medical illness/Infectious Disease Vitamin Deficiency (Thiamine, Vit B12 and Folic Acid) Neoplasm and paraneoplastic syndrome Trauma, subdural hematoma, hydrocephalus Delirium Depression  Diagnostic Studies (primarily done to rule out other illness) ❖ Complete blood count ❖ Complete metabolic panel ❖ Urinalysis ❖ Liver function studies ❖ Thyroid panel ❖ Vit B12 and folate levels ❖ Syphilis serology ❖ CT and/or MRI Pharmacological Management: Mild to Moderate *** important to note that meds do not reverse only slow progression Name Acetylcholinesterase Dosage Side Effects Inhibitors Comments Donepezil (Aricept) 5mg once daily Serious reactions include Educate caregivers on Max: 23 mg once daily arrhythmias (bradycardia, signs and symptoms of GI QT prolongation, torsade bleed de pointes, AV block); GI EKG prior to initiation bleeds, seizures galantamine 4mg BID Max: 24mg BID Serious reactions include Similar MOA to (Razadyne, ER: 8 mg once daily Max: 24mg Stevens-Johnson donepezil; see above once daily syndrome Razadyne ER) for monitoring and considerations Pharmacological Management – Moderate to Severe NMDA Receptor Antagonists Name Dosage Side Effects/Monitoring Comments memantine (Namenda) 5mg BID Common reactions Renal adjustment for Max dose: 20mg BID include headache, severe renal disease dizziness, mood/affect (CrCl 65) but can happen at any age Associated with longer lengths of stay, increased rates of admission to nursing homes  Etiology Medications (ex. Anticholinergics, benzodiazepines) Alcohol or drug use or withdrawal Medical condition such as a stroke, heart attack, worsening lung or liver disease, or an injury from a fall Electrolyte imbalances Severe, long-lasting illness or terminal illness Infection (ex. UTI, pneumonia, flu) Exposure to a toxin, such as carbon monoxide, cyanide or other poisons Poor nutrition Lack of sleep or severe emotional distress Pain Surgery or another medical procedure that requires being put in a sleep-like state Risk Factors Presentation Fluctuate between periods of lucidity inattention/high distractibility Motor restlessness Speech that is difficult to follow Perceptual disturbances - misinterpretations of environment, frank visual hallucinations Memory impairment in relation to recent events Disorientation to time or place May exhibit affective signs of fear, anxiety or anger Symptoms may be worse in the late afternoon or evening - “sundowning” Diagnosis Detection relies on information from patient or reliable informant, records of pre-admission functional status and repeated clinical observation Most commonly used dementia screening tool Confusion Assessment Method (CAM) Evaluates four key features of delirium: 1.Acute Change in Mental Status with Fluctuating Course; 2.Inattention; 3.Disorganized Thinking; 4) Altered Level of Consciousness Differential Dx Dementia Depression Psychosis Vitamin B1 and B12 deficiency Thyroid disorders Infections such as HIV and neurosyphilis Treatment Aimed at identification and treatment of precipitating causes Care is directed at management of symptoms: agitation, restlessness and hallucinations Pharmacological Treatment Antipsychotic medication is used for severe agitation and risk for harm ○ Haloperidol (Haldol): 0.5-1 mg given PO, IV, or IM max dose 5 mg/day Onset of action: 5-20 mins if given IV, longer if given IM or PO IV use is associated with prolonged QT, higher incidence of extrapyramidal effects in dose > 4.5 mg/day Newer atypical antipsychotic agents with similar efficacy/less side effects ○ Quetiapine ○ Risperidone ○ Ziprasidone ○ Olanzapine Non-pharmacological prevention/treatment Orientation protocols- clocks, calendars, windows, verbal reorienting Cognitive stimulation - daytime visits from family/friends Facilitation of sleep - reduce noise, avoid frequent waking/night time procedures Early mobilization, limited use of physical restraints Visual or hearing aids avoiding/monitoring use of problematic medications (ex. Benzodiazepines, opioids, dihydropyridines, antihistamines) Avoiding/treating medical complications (ex. Dehydration, hypoxemia, infections) Managing pain - non-opioids if possible  Delirium Management Algorithm