Delirium and Dementias

Salina Chan 2013

Julius Elefante & Brynn Fredricksen 2014

Outline

• Delirium

• Dementia• Alzheimer’s Disease

• Vascular Dementia

• Lewy Body Dementia

• Parkinson’s Disease

• Management

Delirium

• Independent risk factor for mortality• Increased morbidity, prolonged hospital stays and cognitive

deterioration

• Marker for serious & potential life-threatening med problems

• Found in up to 25% of geriatric admissions

• Associated with mortality and morbidity• Est mortality 22-76%

• Increase risk to staff due to behavioural issues

Delirium Epidemiology

Delirium: DSM-5 Criteria

1. Disturbance in attention

2. Develops acutely and fluctuates

3. Additional disturbance in cognition

4. Not explained by another evolving neurocognitive disorder or a severely reduced LOC (e.g., coma)

5. Evidence that it is a direct physiological effect of another medical condition or is due to multiple etiologies

CLINICAL FEATURES

• Acute onset

• Prodromal phase

• Fluctuating

• Psychomotor disturbance

• Disturbance of consciousness

• Inattention

• Disruption of sleep and wakefulness

• Emotional disturbance

• Disorders of memory and orientation

• Disorders of thought

• Disorders of language

• Perceptual disturbances

CLINICAL VARIANTS

• Hyperactive• Restless/agitated

• Aggressive/hyper-reactive

• Autonomic arousal

• 15-47% of cases

• Mixed• 43-56% of cases

• Hypoactive• Lethargic/drowsy

• Apathetic/inactive

• Quiet/confused

• Often escapes diagnosis

• Often mistaken for depression

• 19-71% of cases

Exercise 1

• Let’s work out an approach to Delirium

• One slim column “DIMS”

• One fatter column

• Four rows. One letter of DIMS per row

Exercise 1

Drugs

Infectious

Metabolic

Structural

RED FLAGS

Exercise 1

Drugs • Drugs of abuse• Meds – anticholinergics, narcotics, BDZ, steroids,

immunosuppresives, antiparkinsonian agents, cimetidine, antibiotics, Li, MAOIs

• Toxins – CO, heavy metals, organophosphates, volatiles, anticholinesterase

Infectious • Pneumonia, UTI, sepsis (Temp >38 or <36, HR >90, RR>20 or PaCO2 <32, WBC >12 or <4 or >10% bands)

Metabolic • Acid-base, fluid/electrolyte, hypoglycemia, DKA, hypoperfusion, hypothermia

• Hypertensive encephalopathy, CHF, low PaO2 or high PaCO2, hepatic failure, renal failure, thyroid, other endocrinopathies

Structural •Infarction, ischemia, neoplasm, stroke•Other CNS process: vasculitis

RED FLAGS “WHIMPS”: Withdrawal, Wernicke, hypoglycemia, hypoxia, hypoperfusion of CNS, hypothermia, hypertensive encephalopathy, ICH, infection, metabolic, poisons, status epilepticus

Delirium homework

• Take your known delirium mnemonics, such as IWATCHDEATH and the previous slide and slot them into DIMS

The Workup

• Suspicion that it is delirium (by definition)

• DIMS differential guides history, physical exam and laboratory workup• AIM is two-fold: rule out immediately life-threatening

causes, and defining the cause(s)

• History often obtained from collateral

• Look for the prodrome: increasing moments of confusion days before, irritability, day/night reversal

Multimodal approach in treatment

1.Address underlying cause(s)• Can often be multifactorial

2.Safety of patient and staff

3.Manage • Non-pharmacological

• Pharmacological

Management of Delirium

• Sleep, sleep, sleep! (at night)• Which of the following should you avoid: melatonin,

trazodone, zopiclone, AP

• AntiΨ meds txn of choice for short-term till delirium subsides• mortality/morbidity• Ensure safety of Pt/Staff

• Aim: to restore Da-Ach imbalance,

• Assumes risk of delirium > risk of AntiΨ

• Haloperidol vs. loxapine

• Risperidone, olanzapine, quetiapine

Delirium: Pharmacological Tx

Capacity vs Competency

• Competency:• Having the ability to understand and act reasonably

• A legal term

• Decision made by a judge

• Capacity:• Having the mental ability to make a rational decision

based on understanding and appreciating all relevant info

• Determined by a clinician

Brain – Quickie Review

Neurocognitive Disorder (“Dementia”)

• Major or mild

• Progressive decline of mental functions• Reasoning

• Memory

• Language

• Problem-solving

• Attention

• Greatly impairs daily function

• Disease seen more in elderly but NOT a normal part of aging

Dementia Criteria(DSM-5: Major and Mild Neurocognitive Disorder)

• Cognitive decline from a previous level of performance in > 1 cognitive domains such as:• complex attention

• executive function

• learning and memory

• language, perceptual-motor

• social cognition

• Based on info from pt, colateral, or clinician and formal testing

• The cognitive deficits interfere with independence in everyday activities

Specifiers

• Alzheimer’s

• FTD

• Lewy body

• Vascular

• TBI

• Substance

• HIV

• Prion

• Parkinson’s

• Huntington’s

• Another medical condition

• Multiple etiologies

• Unspecified

Dementia Types

Dementia Prevalence

Alzheimer’s Dementia

• The development of multiple cognitive deficits manifested by memory impairment AND

• One (or more) of the following cognitive disturbances: • Aphasia (language disturbance, e.g. word-finding difficulties)

• Apraxia (impaired ability to carry out motor activities despite intact motor function)

• Agnosia (failure to recognize or identify objects despite intact sensory function)

• Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting, judgement)

• Gradual onset

• Cognitive Decline

Alzheimer’s Disease

Risk Factors for AD

• Age

• Systolic bp >160 mm Hg

• Total serum chol > 6.5 mmol/L

• Smoking

• Head injury w/ LOC

• Genetic risk factors/family hx late vs early onset

Alzheimer’s Disease

Vascular Dementias

• Step-wise decline

Vascular Dementia Presentation

• Confusion, restlessness, agitation

• Reduced ability to organize thoughts/actions, e.g. difficulty deciding what to do next

• Attention/concentration difficulties

• Memory and speech/language problems

• Unsteady gait & frequent falls

• Incontinence

• Personality & mood changes

• Sudden or frequent urge to urinate

• Wandering at night

Alzheimer’s vs Vascular

Lewy Body Dementias

• Second most common type of progressive dementia

• Lewy bodies = protein deposits

• May cause visual hallucinations, which generally take the form of objects, people or animals that aren't there

• May have sig fluctuations in alertness and attention• E.g. daytime drowsiness or periods of staring into space

• Parkinson-like features, e.g rigid muscles, slowed movement and tremors

• sensitivity to neuroleptics

Lewy body

Parkinson’s Disease

• Usually begins in 60’s

• Characterized by triad of rigidity, bradykinesia and tremor at rest 

• Correlates with degeneration of dopaminergic nigrostriatal pathway and dopamine depletion in the striatum

• rigidity

• tremor at rest

• Slow movement

• Expressionless (mask-like) face

• Stooped posture

• Shuffling, small-step gait

Parkinson’s Disease

Depigmentation of the substantia nigra in PD (left). Normal sustantia nigra (right).

Other Types of Dementias

• Huntington’s• Movement disorder, genetic

• Pick’s• Frontotemporal dementia: • disinhibition/lethargy/executive dysfunction

• HIV

• Creutzfeld-Jacobs Disease

Initial and prominent features

• AD: short term memory loss, progressive memory impairment, disorientation, A3

• Vascular: apathy, gait, memory, visuospatial, processing, memory, stepwise decline

• LWB: Parkinsonism, episodic fluctuations in arousal and alertness, VH or illusions, Capgras, autonomic dysfunction, worsens with D2 block

• FTD: 50s & 60s, personality changes, disinhibition, aphasia if left sided, memory relatively preserved

• NPH: after trauma, infection or hemorrhage, W triad, slowed verbal responses

• **ALL CAN HAVE DEPRESSIVE OR PSYCHOTIC SYMPTOMS**

Primary Prevention

• Lifestyle

• Pharmacological

Primary Prevention: Lifestyle

• Exercise

• Wine consumption• 250 - 500ml/day

• Daily mental activities

• Prevention of head injuries

• Smoking cessation

• Diet: omega 3 FA’s, Mediterranean diet

• Education: 15 yrs vs <12 years RR=0.48

• Enviro exposure: pesticides, fertilizer, fumigants

Primary Prevention: Pharmalogical

• NSAID’s

• Vitamin E & C supplements

• HRT

• Ginko biloba – poor evidence, risk of bleeds

• Statins – poor evidence for primary prevention

• All of these are mentioned but the evidence base is poor

Assessment: History

• Course of illness

• Relation to vascular events ie. strokes

• Hx of EtOH abuse, renal failure

• Vascular risk factors

• Other risk factors

Assessment:Brief Cognitive Tests

• MMSE• Memory

• Attention

• Construction

• Orientation domains

• Clock drawing exercise• General executive fxn of frontal lobe

• Visuospatial abilities

Assessment: Investigations

• CBC (anemia)

• TSH (hypothyroid)

• Lytes (hyponatremia)

• Ca (hypercalcemia)

• Mg

• Fasting glucose (hyperglycemia)

• B12 level (low)

• Folate or RBC folate (low) celiac, inadequate diet

• BUN

• CR

• LFTS

• CXR

• Ur Cx

• Bld Cx

• Homocysteine - insufficient evidence

Assessment:Neuroimaging

• Age < 60 years

• Rapid (1–2 mos) unexplained decline in cognition or function

• Short duration of dementia (< 2 years)

• Recent and significant head trauma

• Unexplained neurologic symptoms (ie. new onset of severe headache or seizures)

• History of cancer (esp w/ brain mets)

Dementia Management

• Medical Workup and Treatment – VINDICATE

• Rule out and treat depression

• Functional and Safety Assessment

• Psychoeducation (family)

• Medications

• Environmental• Nursing home, home care supports

Tx: Pharmacological

Cholinesterase Inhibitors

• Donepezil

• Galantamine

• Rivastigmine – do not use with delirious patients! 22% mortality in 2010 Lancet RCT among ICU patients… this is in the Rivastigmine arm. Yes, the study had sufficient power.

NMDA Receptor Antagonists

• memantine

Cholinesterase Inhibitor

• RCT’s: consistently modest benefit in cognition, ADL & overall clinical state with all three agents

• Adverse effects• GI (anorexia, N&V, diarrhea)

• Dizziness

• Sleep disturbances/vivid dreams (Donepezil)

Tx: Combinations

• RCT compared memantine + donepezil to donepezil alone in patients with mod -severe AD• Better scores on measures of cognition ADLs, global

outcomes & behavior

• Dropout rate < control

• Memantine often added to cholinesterase inhibitor in patients with advanced disease