MD FRCPC Geriatric Medicine A learning module for clinicians This module is part of the sfCare approach 2 PowerPoint Presentation 85 x 11 Poster Patient Handout This module follows the Delirium introductory module for clinicians ID: 917709
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Slide1
Delirium in Dementia
Eric KC Wong
, MD FRCPC
Geriatric Medicine
A learning module for clinicians
Slide2This module is part of the sfCare approach
2
PowerPoint Presentation
8.5 x 11 Poster
Patient Handout
This module follows the Delirium introductory module for clinicians.
Slide3Recognize the relationship between delirium and dementia
Distinguish between delirium and dementia
Apply a practical approach to assessing delirium in dementia
Describe treatment implicationsApply a structured approach to delirium detection in dementia using case studies
Explain approaches to delirium in the communityApply a senior friendly approach to delirium
ObjectivesRelationship between delirium and dementiaHow to distinguish delirium from dementiaPractical approach to assessmentTreatment implications
Case studiesApproaches in the community
Senior friendly
approach
Questions
Objectives
NOTE: Diagnosis of dementia is beyond the scope of this module
Slide4Delirium is a risk factor for future dementia, but baseline dementia is also a risk factor for delirium incidence
Cognitive impairment leads to brain vulnerability and reduced reserve, which increases the likelihood of delirium from a mild precipitant. E.g. change in medication, UTI, pain
Delirium increases dementia risk by unknown mechanisms.Those who experienced delirium have
increase brain atrophy.Clinicopathologic correlates show that patients with dementia after delirium don’t exhibit the typical pathology
of Alzheimer’s disease or Lewy body dementia, suggesting a separate pathway of neuroinflammation.Relationship between delirium and dementia
Lancet Neurol 2015; 14: 823–32 | Brain 2012: 135; 2809–2816 ObjectivesRelationship between delirium and dementia
How to distinguish delirium from dementiaPractical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide5Relationship between delirium and dementia
Alzheimer’s & Dementia 12 (2016) 766-775 | Brain 2012: 135; 2809–2816 | N Engl J Med, 367 (1), 30-9
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementia
Practical approach to assessmentTreatment implicationsCase studies
Approaches in the communitySenior friendly approachQuestions
Slide6How to distinguish delirium from dementia
Neurology, 54 (11 Suppl 5), S4-9 2000
Alzheimer’s disease is the most common type of dementia, and it can be easily separated from delirium because of its insidious slow onset and
preservation of attention in the early stages. Lewy body dementia
is a less common type of dementia, but it can mimic delirium because of its fluctuating course and inattention. Since dementia and delirium both feature disorientation, short term memory loss, hallucinations/delusions, and agitation/restlessness, it’s important to learn
how to distinguish the two diseases.ObjectivesRelationship between delirium and dementia
How to distinguish delirium from dementiaPractical approach to assessmentTreatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide7How to distinguish delirium from dementia
J Neurol Neurosurg Psychiatry, 75 (3), 382-7 Mar 2004.; J Neuropsychiatry Clin Neurosci, 25 (2), E27-8 Spring 2013; Neurology 2017; 89 (1) July 04
Delirium
Lewy body dementia (DLB)
Alzheimer’s disease (AD)
Onset
Acute
Insidious
Insidious
Course
Fluctuating
Fluctuating (but not always), progressive
Progressive
Attention
Always inattentive
Periods of inattention
Attentive in early-to-moderate stages in the disease
Alertness / motor subtype
May be
drowsy
(hypoactive) or
restless/agitated
(hyperactive)
Usually
drowsy
(but may be restless/agitated)
Usually
restless/agitated
Cognitive Testing
Impaired across all domains due to inattention or mainly in executive function
Impaired mainly in executive function and visuospatial domains early in disease
Impaired mainly in delayed recall early in the disease
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide8Clinical description of the fluctuations
Deviates from the patient’s usual behavioural patterns
, either by timing or severity.
Associated with
precipitant (change in medications, infections, hospitalization etc.)
Fluctuations may last hours or days and does not follow a pattern (unlike sundowning).
Fluctuations have been described in detail previously and are typically delirium-like, occurring as spontaneous alterations in cognition, attention, and arousal not due to a precipitating factor
Characteristics of fluctuations:
Include waxing and waning episodes of behavioral inconsistency, incoherent speech, variable attention, or altered consciousness that involves staring or zoning out.
Direct questioning of an informant about fluctuations may not reliably discriminate DLB from AD, but questions about daytime drowsiness, lethargy, staring into space, or episodes of disorganized speech do.
Sundowning is NOT considered fluctuations.
Sundowning is a pattern of worsening neuropsychiatric symptoms in the afternoon/evening hours in patients with dementia
Sundowning
u
sually occurs in the moderate-to-late stages of the disease
Delirium
DLB
AD
Slide9Practical approach to assessment
Check with an informant
Look for fluctuations
Assess for inattention
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide10Check with an informant
The most reliable way to determine whether someone with dementia has delirium is by an informant
(e.g. family, caregiver) who knows the patient well.
“
Do you think [name of patient] has been more confused lately?” (ref: Single Question in Delirium, 91% sensitivity for delirium)If family not available, call the nursing home, ask the LHIN case manager, or anyone else who interacts with the patient regularly.
Practical approach to assessmentLook for fluctuations. If the patient experiences periods of lucidity in between episodes of increased confusion, the patient likely has delirium.
Look for fluctuations
Age & Ageing 2016 45(6):832-837
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide11Practical approach to assessment
Since inattention is always present in delirium, you can rule out delirium in someone who is attentive. You can use a bedside test to determine whether someone is inattentive.
Assess for inattention
Tests
Sensitivity (%)
Specificity
(%)
Serial 7s
95.7
13.7
Serial 3s
87.0
47.0
Months of the year backwards
82.6
62.5
Days of the week backwards
47.8
85.1
Counting 1-10
17.4
91.1
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Int
Psychogeriatr
. 2016 Aug;28(8):1293-301. | Age Ageing. 2015 May;44(3):537-8.
Slide12Cut off for months of the year backwards
When asking the patient to recite the months of the year backwards from December, different experts use different cut offs to define inattention. The patient should at least be able to get to July.
Assess for inattention
Cutoff
Sensitivity (%)
Specificity
(%)
Derived from
<5/12 (July)
82.0
66.0
Adamis et al. 2016
<5/12 (July)
91.3
49.7
Hendry et al. 2016
<7/12 (May)
93.1
49.8
4AT
<12/12 (All)
82.6
62.5
Voyer et al. 2016
MOTYF
26.1
89.3
Voyer et al. 2016
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide13Treatment implications
Delirium care is attentive, patient-centred care. There is no harm applying non-pharmacologic delirium care strategies to someone with dementia, so when in doubt, treat the patient for delirium. Recall the management strategies from the previous module, which includes:
Frequent reorientation with calendar/clock/window visible
Adequate hydration and nutritionMobilization including sitting in a chair for meals
Put on (clean) glasses and hearing aidsEnsure good sleepNon-caffeinated warm drink before bed
Encourage family to be present if possible, and provide information on how they can help
ObjectivesRelationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide14Treatment implications
Detecting parkinsonism is particularly important when treating delirium. The principal harm is the use of high potency antipsychotics in a patient with parkinsonism.
Patients with primary Parkinson’s disease or Lewy body dementia are sensitive to antipsychotics because dopamine (D2) antagonism will lead to worsening of rigidity and parkinsonism, which will likely lead to more discomfort and agitation.
Everyone should check the patient’s medical history for a diagnosis of Parkinson’s or Lewy body dementia. The medical expert should learn to examine a patient for signs of Parkinson’s.
Patients with parkinsonism
Parkinson’s disease (PD) symptoms on exam:Slow movementsLittle facial expression (hypomimia)Slow blink rateIncreased tone on passive range of motion
Slow, shuffling gait with stooped posture and little arm swingUnilateral rest tremor (present in 70% of PD patients
)
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide15Treatment implications
In patients with parkinsonism who need pharmacologic therapy for delirium, low dose quetiapine should be tried first (12.5mg po qhs or bid depending on timing of symptoms).
Experienced clinicians may use:Clozapine: need to monitor for agranulocytosis (1-2%) with serial CBCs
Pimavanserin: antagonist of 5-HT2A receptor with no D2 activity. Clinical trials have shown no increase in rigidity, but the medication is not approved in Canada or Europe yet.
If the patient is on dopaminergic drugs (e.g. levodopa, pramipexole), consider lowering doses slowly if contributory to symptoms.
Patients with parkinsonismObjectives
Relationship between delirium and dementiaHow to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Expert
Opin
Pharmacother
, 19 (5), 499-505 Apr 2018
Slide16Case Study 1: Mr. J
Mr. J is an 80 year old male who was brought by his daughter to the hospital for visual hallucinations and confusion.
How will you start your assessment?
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementiaPractical approach to assessmentTreatment implicationsCase studiesApproaches in the communitySenior friendly
approachQuestions
Diagnosing a delirium with underlying dementia
Slide17Case Study 1: Mr. J.
Is this delirium? Is there underlying dementia? If it is delirium, what’s the precipitant?
refer to first moduleHow to treat?
How will you start your assessment?
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementiaPractical approach to assessmentTreatment implicationsCase studies
Approaches in the communitySenior friendly
approach
Questions
Slide18Case Study 1: Mr. J
Speak to an informant who knows the patient well (such as family or caregiver). Ask the informant if the patient appears more confused than usual.
Is this delirium? Is there underlying dementia?
Check with an informant
When did the confusion start?
“He has been ‘confused’ for the last 2 years, getting worse. He frequently forgets conversations and where he put things.”
What was the patient’s cognitive baseline 1 week or 1 month ago?“He was much better a few days ago! The hallucinations only started about 2 days ago. He also started feeling short of breath at the same time.”
Does the patient have diagnosed dementia? If so what type?
“No, at first we thought it was just because he’s getting old. Do you think he has dementia?”
It’s common for delirium to be the first presentation of dementia because caregivers may attribute symptoms of early dementia to normal aging.
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide19Case Study 1: Mr. J
Is this delirium?
Check the nurse’s or physician’s charting to see if the patient’s mental status is fluctuating.
Look for fluctuations
Assess for inattention + orientation
Speak to the patient to get a sense of
orientation
and
attention
level.
Ask the patient to recite the months of the years backwards from December
Patient gets stuck at November
Ask the patient for orientation to place and time, and compare this with his baseline via informant history (if available).
He is disoriented to time and place
CAM criteria
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide20Summarizing the approach to criteria 1 and 2 from CAM
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementia
Practical approach to assessmentTreatment implications
Case studiesApproaches in the communitySenior friendly
approachQuestions
Slide21Case Study 1: Mr. J
There’s an acute change on a background of chronic progressive cognitive impairment. Tests for
inattention were positive and the patient had disorganized thinking (disorientation and hallucinations). CAM criteria fulfilled
Mr. J appears to have delirium superimposed on dementia
After the delirium resolves, you refer the patient to a geriatrician for dementia diagnosis. The geriatrician sends you a consultation note thanking you for identifying an underlying dementia syndrome. The patient was diagnosed with Alzheimer’s disease.
ObjectivesRelationship between delirium and dementia
How to distinguish delirium from dementiaPractical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide22Case Study 2: Mrs. C
You are called to examine an 85 year old female who was admitted to hospital for heart failure. She developed
delirium on day 2 of her hospital stay and is agitated, trying to pull out her IV and striking out at the nurses.After optimizing the patient’s medications, pain, dyspnea, volume status and electrolytes, she’s still agitated and at risk of harming herself and others.
An antipsychotic is required to prevent further harm and restraint use. You proceed to the antipsychotic checklist from the previous module.
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementiaPractical approach to assessment
Treatment implicationsCase studies
Approaches in the community
Senior friendly
approach
Questions
Treatment of delirium
Slide23If a patient requires antipsychotics, rule out parkinsonism
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementiaPractical approach to assessment
Treatment implicationsCase studies
Approaches in the communitySenior friendly approach
Questions
Slide24When you examine Mrs. C, you find that she has some rigidity in her arms and legs and her voice appears quiet. Her niece also tells you that the she has been slowing in movement and walking for the last 5 years and getting worse.
You determine that Mrs. C likely has parkinsonism, and document that you will avoid giving high potency antipsychotics (e.g. haloperidol or risperidone).
You write an order for quetiapine 12.5mg po qhs.
Case Study 2: Mrs. C - Resolution
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementiaPractical approach to assessmentTreatment implicationsCase studies
Approaches in the communitySenior friendly
approach
Questions
The patient’s delirium resolves gradually over the next week, and you discontinue the quetiapine prior to discharge. You refer Mrs. C to a geriatrician or neurologist for assessment of Parkinson’s disease and cognitive testing.
Slide25Delirium typically requires in hospital investigation and treatment.
Following an episode of delirium, community providers should screen for cognitive impairment after waiting for full resolution (may take months).
Although the Canadian Task Force for Preventative Health Care recommends against screening asymptomatic older adults for dementia, patients who have experienced delirium should be screened for dementia because they are not “asymptomatic”. Expert consultation by geriatrician, geriatric psychiatrist or neurologist may be requested for dementia diagnosis.
Approaches in the community
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementiaPractical approach to assessmentTreatment implications
Case studiesApproaches in the community
Senior friendly
approach
Questions
https://canadiantaskforce.ca/cognitive-impairment-clinician-summary/
Slide26The senior friendly approach
Ask leaders to remove barriers to care, and provide education for staff, patients and caregivers.
Treat delirium as a medical emergency, as you would for adults of all ages.
Involve family in the prevention, identification, and treatment of delirium in dementia.
Make the environment calming and orienting by having familiar people present, lights on, reduce noise, etc.
Organizational Support
Emotional &
Behavioural
Environment
Ethics in Clinical Care and Research
Physical Environment
Processes
of Care
How all healthcare providers can address delirium using a
senior friendly care
approach
Organizational Support
Ethics in Clinical Care and Research
Processes
of Care
Emotional &
Behavioural Environment
Physical Environment
Objectives
Relationship between delirium and dementia
How to distinguish delirium from dementia
Practical approach to assessment
Treatment implications
Case studies
Approaches in the community
Senior friendly
approach
Questions
Slide27Have you encountered cases of delirium superimposed on dementia? What were some challenges with diagnosis? Management?
How do you engage families in determining whether someone has delirium or dementia?
What ideas can you implement from today’s module?
Discussion questions
Objectives
Relationship between delirium and dementiaHow to distinguish delirium from dementiaPractical approach to assessmentTreatment implications
Case studiesApproaches in the community
Senior friendly
approach
Questions
Slide28Thank you to Dr. David Tang-Wai for providing expert guidance on how to distinguish delirium from the dementia syndromes.
Acknowledgement
Slide29The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care.
V1
January 2020