Evaluation and Management of Delirium and Dementia

Dementia is an illness defined by the presence of progressive irreversible multiple cognitive deficits which interfere with the individuals day to day activities, marked by a decline in functioning, characterized by a change in personality behavior

Evaluation and Management of Delirium

and Dementia

Dr.M.Ashfaq Burney

• Definitions

• Epidemiology

• Delirium assessment, diagnosis, management

• Dementia assessment, diagnosis and

management

• What are normal memory lapses?

Memory in daily task:Forgetting an

acquaintance name.

Performance of tasks:Leaving food to burn

Language:Trouble finding the right word

Orientation:Forgetting the day or date

Judgment:Choosing to wear a light sweater

on a cold night

Abstract thinking:Making a mistake in

balancing cheque book Temporarily misplacing car keys or glasses Gradual perceptible change in personality

and mood Initiative:Occassional tiredness from doing

house work and social obligation.

Memory in daily task: Unexplained confusion in familiar places

Performance of familiar task: Forgetting

to serve meal after preparing

Language: Forgetting simple words or

Misplacing objects: Putting iron in freezer

and wrist watch in bowl

Personality: Severe Moods swings

Initiative: Sustained lack of interest.

CASE

• Dr X was a 74-year-old retired professor, recently diagnosed with

Alzheimer's disease He had been started a trial of acetyl cholinesterase inhibitor and had shown a promising early response An elective

orthopedic procedure was planned Care was taken to optimize his

medical status ahead of time The operation proceeded uneventfully and eighteen hours postoperatively he was doing very well He was discharged home in stable condition In the early hours of the morning following

discharge, he suddenly became confused and called out He was taken to the near by clinic, where he was given 5 mg of haloperidol and sent home

In the view of the family who were caring for him the drug was found

ineffective, as his confusion and agitation worsened So he was taken to your clinic the same day in night

Examination showed an extremely agitated, restless man in considerable psychological distress He was in physical restraint, not recognizing his

wife

• What's going on?

• What would be your response?

• Dr X was a 74-year-old retired professor, recently diagnosed with

Alzheimer's disease He had been started in an open-label trial of acetyl

cholinesterase inhibitor and had shown a promising early response An

elective orthopedic procedure was planned Care was taken to optimize his medical status ahead of time The operation proceeded uneventfully

and eighteen hours postoperatively he was doing very well He was

discharged home in stable condition In the early hours of the morning

following discharge, he suddenly became confused and called out. He

was taken to the near by clinic, where he was given 5 mg of haloperidol

In the view of the family who were caring for him the drug was found

ineffective, as his confusion and agitation worsened. So he was taken to your clinic the same day in night

Examination showed an extremely agitated, restless man in considerable psychologic distress He was in physical restraint and not recognizing his

wife

• What's going on?

• What would be your response?

Delirium Refer

Do CAM

Do MMSE Stop all the medication Get medical investigations done

Hyponatermia was found to be the cause.

Later was discharged.

Other than difficulty with stairs and the bathtub, he was independently mobile and required no assistance in

activities of daily living

Definition of Delirium (Acute Confusional State)

Delirium is characterized by

• Disturbance of consciousness

• Change in cognition that develops over a short period of time.

The disorder has a tendency to fluctuate during the course of the day.

There is evidence from the history, examination or

investigations that delirium is a direct consequence of a

general medical condition, drug withdrawal or intoxication .

Cognitive Impairment

• Is a broad term to describe a wide variety of impaired

brain function relating to the ability of a person to:

abilities that have minimal impact

on day-to-day functioning and does not meet criteria for dementia

Vitamin B12 deficiency Thyroid disease Alcohol related

Neurosyphilis HIV related Herpes simplex encephalitis Creutzfeldt Jacob disease Brain tumor and NPH Complex epilepticus

Depression, delirium, trauma,

metal toxicity, MS

Delirium Stats

 Overall prevalence of delirium in the community is only 1 to 2

percent, the prevalence increases with age, rising to 14

percent among those more than 85 years old.

 Delirium at admission: 14-24%, during hospital stay 6% to

65%, post operatively 15% to 53%.

 54% Delirious Elderly Patients NOT Recognized By Physicians

And Nurses.

 60% of patients in nursing homes or post acute care setting.

 The one-year mortality rate associated with cases of delirium

is 35 to 40%.

Delirium is common among older adults in acute care settings (prevalence estimates typically range

from 10–60%).

• Severe illness, admission

to intensive care unit

• Vision or hearing impairment

Precipitants

Electrolyte abnormalities Environmental factors (e.g., excessive noise, interrupted sleep, unnecessary stimuli) Hypoxia, hypoglycemia, or ischemia

Medications (especially Anti-cholinergics, narcotics, and sedative-hypnotics) Neurological disorder (e.g., stroke, seizures) Pain

Sleep deprivation Surgery

Urinary catheter

• Anticonvulsants Barbiturates

• Anti-parkinsonian agents Benztropine, trihexyphenidyl

• Antipsychotics Tricyclic antidepressants, Lithium,

• Sedatives Benzodiazepines

• Histamine H2 blockers Cimetidine, Ranitidine

• Anti nauseants Scopolamine, Dimenhydrinate

• Antihistamines HI Blocker Hydroxyzine

• Cardiac medications Antiarrhythmics B-blockers, Methyldopa

• Onset and course of confusion

• Previous intellectual functions (e.g ability to manage household affairs, pay bills, compliance with medication, use of telephone and transport)

• Co morbid illness

• Full drug history including non-prescribed drugs and recent drug cessation

(especially Benzodiazepines)

• Alcohol history

• Previous episodes of acute or chronic confusion

• Functional status (e.g activities of daily living)

• History of diet and food intake

• History of bladder and bowel voiding

• Aids used (e.g hearing aid, glasses etc)

• Social circumstances and care taker detail

Personality, mood and behavior changes

Wherever possible corroboration

should be sought from the care giver,

or any source with good knowledge of the patient

Activity of daily living (ADL):

HEAD TO TOE EXAMINATION, INCLUDING SYSTEMS.

CAM/MMSE/

MINICOG ADL: DEATH IADL:SHAFT

Physical Examination

• Conscious level

• Nutritional status

• Evidence of pyrexia

• Search for infection: lungs, urine, abdomen, skin

• Evidence of alcohol abuse or withdrawal (e.g tremor)

• Cognitive function using a standardized screening tool, e.g AMT (ABBREVIATED MENTAL TEST) or MMSE

• Neurological examination (including assessment of speech).

• Rectal examination – if impaction is suspected

Vitals General Exams Systemic Exam

Please memorise the following address

(10) Can you remember the address which I gave you? _

A score of ≤7 out of a possible 10 suggests cognitive impairment.

The six item cognitive impairment test

Six questions

1 What year is it? (correct:0 incorrect:4)

2 What month is it ?(correct:0 incorrect:3)

3 Give the patient an address phrase to remember with five components (such as John Smith, 42 High Street,Bedford)

4 About what time is it (within one hour) correct:0,incorrect:3)

5 Count backwards from 20-1 (correct:0, 1 error:2, >1 error: 4)

6 Say the months of the year in reverse repetition Same as above)

3 Ask the patient to repeat the address phrase requested earlier Correct:0, 1 error: 2, 2 error:4, 3 errors: 6, 4 errors: 8; all incorrect: 10.

0-7= not significant 8-9: probable significant , 10-28: significant.

Handbook of family Medicine 3rd edition

BMJ 2011;343:d5042 doi: 10.1136/bmj.d5042

Cut off 23/24 out of 30.

Mild:> 20

Moderate: 10-19

Severe:<10

 4 Altered Level of consciousness

CAM (Confusion Assessment Method) requires the presence of features 1 and 2

and either 3 or 4.

Is there Acute change in cognition from baseline?

Abnormal behavior fluctuates during the day: comes and goes, increases or

decreases

Easily distractible or losing tract what was being said.

Rambling or irrelevant conversation, unlcear or switching from subject to

subject

Mental status anything beside alert; i.e

hyperalert, drowsy, stuporous, comatose

Hyperactive delirium: is characterized by increased motor activity with agitation, hallucinations and

inappropriate behavior.

Hypoactive delirium in contrast is characterized by reduced motor activity and lethargy and has a poorer prognosis.

INVESTIGATIONS

• Pulse oximetry

• Urinalysis

• Glucose

• Full blood count including C reactive protein

• Urea and electrolytes, calcium, B12 and folate level

• Thyroid function tests

• Arterial blood gases

• Lumbar puncture

Management (NEJM,354;11:CURRENT CONCEPT)

Patient presentation

cognitive assessment, establish

baseline status and evaluate

Prevention of delirium:

Address risk factors Encourage mobilization Use visual and hearing aids Prevent dehydration Provide uninterrupted sleep time, Avoid psychoactive drugs

Change in mental status

Perform dementia

evaluation Perform cognitive

assessment and evaluation for delirium

Delirium confirmed Rule out depression, mania and acute psychosis

Manage symptoms of delirium

Initial evaluation:

Obtain history (including alcohol and

benzodiazepine use)

Obtain vital signs

Perform physical and neurological

examination Lab test Search for occult infection

Review medications

Remove or alter potentially

harmful drugs Change to less noxious

alternative Lower doses Non pharmacological approaches

status Nutritional support

Skin care Pressure sore Mobilization Prevent DVT,PE

Patients with severe agitation

All Patients

Non pharmalogical treatment stratgies

Continue delirium prevention

encourage family involvement

Use sitters Orient the patient Avoid use of physical restraints and

foley’s catheters Use of relaxation technique,music,

massage Use of eye glasses, hearing aids Normalize sleep-wake cycle,discourage

naps Maintain low level light during night

while sleeping.

Drug sedation may be necessary in

the following circumstances:

 to carry out essential

Appropriate lighting levels for the time of day

Regular and repeated (at least three times daily) cues to improve personal

orientation

Use of clocks and calendars to improve orientation

hearing aids and spectacles available as appropriate and in good working order

continuity of care from care taker

Encouragement of mobility and engagement in activities and with other people

patient is approached and handled gently

Elimination of unexpected and irritating noise (eg pump alarms)

regular analgesia, for example regular paracetamol.

Encouragement of visits from family and friends who may be able to help calm the

patient.

Explanation the cause of the confusion to relatives Encourage family to bring in

familiar objects and Pictures from home and participate in rehabilitation.

Fluid intake to prevent dehydration (use parenteral fluids if necessary)

Good diet, fluid intake and mobility to prevent constipation

Good sleep pattern (use milky drinks at bedtime, exercise during the day).

Wandering

Rambling speech

It is usually preferable not to agree

with rambling talk, but to adopt one of the

following strategies, depending on the

circumstances:

• Tactfully disagree (if the topic is not sensitive)

• Change the subject

• Acknowledge the feelings expressed – ignore the content

Prevention of complications

• Fall

• Pressure sores and infections

• Functional impairment – Assessment by a physiotherapist and occupational

therapist to maintain and improve functional ability should be considered in all delirious patients.

• Continence – A full continence assessment should be carried out Regular

toileting and prompt treatment of urinary tract infections may prevent urinary incontinence.

• Malnutrition: Food alternatives that take into account the patient’s preferences.

• Post delirium counseling

• Follow up: Refer the patient to a Geriatrician, Psychiatrist for further assessment and follow-up

 Non convulsive epilepsy / temporal lobe epilepsy

 Deafness (may appear confused)

What to do?

Admit if

The patient lives alone

The patient will be left unsupervised for

any duration of time

Care givers are unprepared or unable to

continue looking after.

History and examination suggesting need.

Management at home

Acute confusion is frightening for care givers,

reassure and support them

Treat the cause.

Avoid sedation except where unavoidable.

If the cause is not clear and patient fails to improve, admit for further investigations and

assessment.

CASE

• Mrs H, 68 years old female, present to your clinic complaining of

memory problem Over the past 3 months she has noted increasing difficulty recalling the names of friends and acquaintances and she reports occasional trouble thinking the proper words to express her thought The day before appointment she found herself in the

garage, unable to remember why she was there or where she

intended to go “I am worried that I am losing my memory and that

I have Alzheimer disease” She says

• What are the test that differentiate normal aging changes from cognitive impairment?

• Are there effective methods to prevent, reverse or slow the progression of cognitive impairment?

Checking of memory in daily task Performance of daily task

Language Orientation Judgment Abstract thinking Mood, behavior and personality

Apply MMSE

or Mini Cog ADL/IADL assessment

• The Mini-Cog assessment instrument combines an uncued 3-item recall test with a clock-drawing test (CDT) that serves as a recall distractor The MiniCog can be administered in about 3 min, requires no special

equipment, and is relatively uninfluenced by level of education or

language differences Administration: The test is administered as follows:

1 Make sure you have the patient's attention. Instruct the patient to

listen carefully to and remember 3 unrelated words and then to repeat the words back to you (to be sure the patient heard them) 2 Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on

a sheet with the clock circle already drawn on the page After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time (11:10 and 8:20 are most commonly used and more sensitive than some others) These instructions can be

repeated, but no additional instructions should be given If the patient cannot complete the CDT in ≤3 min, move on to the next step. 3 Ask the

patient to repeat the 3 previously presented words Scoring: Give 1 point for each recalled word after the CDT distracter Score 0–3 for recall Give 2 points for a normal CDT, and 0 points for an abnormal CDT The CDT is

considered normal if all numbers are depicted, once each, in the correct sequence and position, and the hands readably display the requested

time Add the recall and CDT scores together to get the Mini-Cog Score:

• 0–2 indicates positive screen for dementia • 3–5 indicates negative

orientation Disoriented to date Disoriented to date,

place, getting lost in familiar places

Severe loss of recognition of close family

language Naming difficulty Expression and

comprehension difficulty

Not intelligible verbal output

memory Significant problem Severe prob absent

Long term memory Generally intact Significant problem Absent memory

neurological Difficulty copying or

drawing Impaired calculation skills Total loss

ADL Dressing and groom Urinary accident to

incontinence Assistance required

cook,shop Total loss

This patient doesn’t have any of the above mentioned

issues except memory lapses for 3 months Evaluation revealed she has memory loss only

So she has cognitive impairment.

Here is need to educate about aging and dementia to

the patient and family

Follow up required

Case (cont.)

• 8 years later Mrs H, was brought by her

husband, who states that he is concerned

about her memory problems and her loss of ability to perform previously routine task such

normal She scores 22 on her MMSE, mini cog score is 1 Neurological screening exam and labs are normal.

• What will you do?

CT Head Suggested diffuse atrophy.

37

The estimated worldwide burden is 24.3 million.

disability (YLD) at the global level, accounting for 2% of the total global YLDs

6%-8% in those >or = 65 years

30%-50% of those >= age 85 years

•This number could jump to 80 million by the year 2040.

•60% of dementia unrecognized by family

•64% missed by caregivers and PHYSICIANS.

•Connolly A, Gaehl E, Martin H, Morris J, Purandare N Under diagnosis of dementia in primary care: Variations in the