DEMENTIA AND DELIRIUM Dr Fiona McDowall. - PowerPoint Presentation

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DEMENTIA AND DELIRIUM

Dr Fiona McDowall.Consultant old age psychiatrist

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DEMENTIAS

What is dementiaDemographicsClinical featuresTypes of dementia

Pathology

Diagnosis

Treatment

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What is dementia

Dementia is a clinical term describing a symptom complex characterised by a decline from previously maintained intellectual function

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It occurs in clear consciousness

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Decline affects more than one higher cortical function

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Affects memory, behaviour, personality, judgment, attention, spatial relations, language, abstract thought, other executive functions such as planning and social judgement

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Demographics

>65 population has increased x4 since start of century 18% of the population now > 65 years old

Dementia affects 5% of those > 65

20% of those > 80

Currently the leading cause of death in UK

Globally rise to 132 million by 2050

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Types of dementia

• Alzheimer’s Disease

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Vascular dementia

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Mixed dementia

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Dementia with Lewy Bodies

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Fronto

-temporal Dementia

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Clinical features of dementia

1.Loss of memory and higher brain functions such as planning, decision making, problem solving

2.Impairment of Activities of Daily Living (ADLs)

Washing, dressing, cooking, telephone, TV, money, getting lost, driving, appliances.

3.Behavioural and Psychological Symptoms (BPSD)

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Memory loss in dementia

Types of memory

1) Short-term -

frontal lobes, tested by immediate recall of words or digit span

2) Long-term memory -

limbic system, t. neocortex

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Episodic - personally experienced, temporal -specific

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Semantic - general knowledge and factual

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Information-procedural - learnt tasks

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Memory loss in Alzheimer’s disease

•Temporal gradient of forgetting

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Shrinking repertoire of memories

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Difficulty learning new information

Short term memory loss >long term

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Temporal lobe and dementia

Episodic memory - Limbic system

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Semantic memory - Temporal neocortex

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Dominant hemisphere - Verbal memory

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Wernicke’s dysphasia - Language comprehension

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Non-dominant hemisphere - Visual memory

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Activities of daily living

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Forgetting appointments, medication/repetition

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Living in the past - reminiscing

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Confabulation

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Non-recognition of familiar surroundings

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Parietal lobe and dementia

Functions relevant to dementia symptoms

Dominant hemisphere: Writing/Calculation

R-L orientation

Non-Dominant: Visuospatial perception

Location in space

Apraxia - inability to carry out a task in absence of motor or sensory loss

Agnosia - inability to recognise, despite normal perception

e.g. using money, driving, telephoning, getting dressed, eating, going to the toilet, making a cup of tea

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Frontal lobe and dementia

Working memory Functions relevant to dementia

Controls ‘executive functions’ i.e.

organising, planning, problem solving, sequencing, adapting and learning new tasks

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Personality, especially motivation

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Regulation of social behaviour / initiative

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Motor speech:

Broca’s

area

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Cortical inhibition of bowels and bladder

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Clinical features of dementia

Delusions

Misidentification 30%

Persecution, theft 16%

Hallucinations

- Visual 13%

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Auditory 10%

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Depression 20%

Challenging behaviour (BPSD) - Aggression, Wandering, Agitation, restlessness, ‘

sundowning

’

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Risk assessment and dementia

WanderingNeglectFireFinancial exploitation

Aggression

Driving

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Pathology and dementia

Global cortical atrophyMedial temporal atrophy(hippocampus)Vascular changes

Infarcts

Neurofibrillary tangles, amyloid plaques

Neuronal loss and cholinergic deficits(acetyl cholinesterase inhibitors)

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Risks and protective factors

Risks:Age, genetics, Down’s syndrome, life style, vascular risks, female, head injury.

Protective:

company, IQ, cognitive stimulation, learning new things, life style and diet, decrease the vascular risks.

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Making a diagnosis

History. COLLATERAL very important–

which type of memory loss, examples

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Speech / language difficulties

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Orientation difficulties

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Onset / course of deterioration

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Personality change/ risk/challenging behaviour

_ADLs

FH Positive?

PH educational level/ occupational attainment

Med

Hx

SHx

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Making a diagnosis

Mental state examination:Depression, hallucinations, delusions.Cognitive assessment: ACE-III, Mini-ACE

Cognitive decline in at least two domains(memory, language, orientation, visuospatial, fluency) for at least 6 months

AND decline with function (ADLS)

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Investigations

Brain scansBloods: full confusion screenFBC, ESR/CRP, Us and Es, LFTs, Ca, B12, folate, TFTs, glucose.

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Treatment

Medication: acetyl cholinesterase inhibitors, memantine, antidepressants, antipsychotics.Psychological

Social

Supporting organisations: social care, Alzheimer’s society, carers, home care.

LPA, Advance care plans, driving, will.

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Dementia and the general hospital

1/4 patients in the acute hospital have a diagnosis of dementia1/3 in acute hospital have delirium1/3 patients on an acute take are in the last year of life

Diagnostic overshadowing

Dementia/delirium/depression overlap

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Delirium

DefinitionDiagnosisInvestigationsTreatment

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Delirium definition

Delirium (acute confusional state) is a neuropsychiatric syndrome characterised by acute onset of fluctuating cognition and inattention linked to triggering factors. It usually develops over 1-2 days. Delirium is a serious condition that may be associated with poor outcomes. However it can be prevented and symptoms treated if identified early

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Delirium definition

The American Psychiatric Association’s Diagnostic and Statistical Manual, 4th

Edition (DSM-IV) defines delirium by the presence of 4 key clinical features:

 

Disturbance in consciousness with reduced ability to maintain or focus attention

A change in cognition or development of a perceptual disturbance which is not better explained by a pre-existing dementia.

Acute onset and fluctuating course.

Evidence of a triggering medical condition or causative substance.

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Delirium definition

Symptoms of delirium have a tendency to fluctuate throughout the course of a day, and as such is frequently under recognised. Delirium presents in one of three ways:

 

Hyperactive delirium

: restless, agitated, delusions, hallucinations, risk of harm to patient or others.

Hypoactive delirium

: lethargic, drowsy, reduced communication.

Mixed Delirium

: demonstrates signs of both of the above.

 

Hypoactive and mixed delirium may be more difficult to recognise.

 

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Delirium demographics

Delirium is common in hospital affecting:30% of older medical patients at some point during a hospital admission.

10-50% of patients post operatively.

70-80% of patients in an ITU setting

20% of patients in post-acute care settings

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Delirium demographics

Despite its frequency delirium is under recognised in hospitals. Delirium should be considered a medical emergency and is associated with unfavourable outcomes including:

 

Increased mortality in older people (35-40% at 1 year)

Increased length of stay.

Increased rates of placement in care home.

Increased risk of in-hospital complication such as pressure ulcers and falls.

 

In addition to the above up to 60% of older patients with delirium have persisting cognitive impairment and will go on to receive a diagnosis of dementia.

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Delirium demographics

Delirium is preventable in up to 1/3rd of cases and is treatable if identified and managed appropriately and urgently. As such it should be considered a medical emergency.  

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Delirium differential diagnosis

Diagnoses that may be difficult to distinguish from delirium are dementia, depression, psychotic illness, dysphasia, mania and non-convulsive epilepsy.  

It can be difficult to distinguish between dementia and delirium because symptoms overlap and some patients may have both conditions. Dementia is associated with progressive decline and is irreversible. Delirium is associated with a fluctuating course and may be reversible.  

If clinical uncertainty exists over diagnosis then initial management should be for delirium.

 

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Delirium risk factors

Age 65 years or olderCurrent hip fractureCognitive impairment or dementia

Severe illness

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Delirium risk factors

Co-morbidities

Current hip fracture, clinical frailty, multiple co-morbid conditions, chronic renal or hepatic impairment, history of stroke or other brain injury, dehydration, malnutrition, severe illness

Cognitive status

Existing dementia, past history of delirium, depression

Demographics

65 years +

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Delirium risk factors

Drugs

Polypharmacy (>3 drugs), psychoactive drugs, alcohol or other recreational drug use

Functional status

Immobility, dependant ADLS, history of falls

Sensory impairment

Visual or hearing loss

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Delirium diagnosis and assessment

  History

 

It may not be possible to obtain a history from the patient although reasonable attempts should be made. A collateral history should be sought which in addition to standard questions should include the following:

Previous cognitive function

Previous episodes of delirium

Functional status

Sensory deficit

Usual communication method

Symptoms suggestive of underlying cause

Drug history including alcohol

 

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Delirium diagnosis and assessment

Physical examination 

A full clinical examination should be carried out and should include:

Neurological examination

Rectal examination

Glasgow Coma Scale (GCS)

Pain assessment (Abbey pain score)

Assessment of pressure areas

Nutritional assessment (MUST)

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Delirium diagnostic tools

Confusion Assessment Method (CAM)  

The diagnosis of delirium requires the presence of point 1 and 2 and either 3 or 4:

Acute onset and fluctuating course

Inattention

(inability to concentrate)

Disorganised

thinking (rambling, illogical ideas)

Altered level of consciousness

(hyper alert or drowsy)

 

The CAM has a sensitivity of 94-100% and specificity of 90-95% when applied by a person competent in identifying delirium.

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Delirium diagnostic tools

4A Test (4AT)  

Patients are scored on 4 categories:

Alertness

: Normal =0 Mild sleepiness = 0 Clearly abnormal = 4

AMT4

(age, place, building, DOB): No error = 0 1 error = 1 2 or more error = 2

Attention

(list months of the year backwards): 7 months or more = 0 starts but less than 7 months = 1 Untestable/doesn’t start = 2

Acute change or fluctuating course

: No = 0 Yes = 4

 

A score of 4 or above indicates delirium +/- cognitive impairment, 1-3 indicates cognitive impairment, 0 suggests cognitive impairment/delirium unlikely.

 

The 4AT is less subjective than the CAM and does not require special training. It also allows screening of ‘untestable’ patients (those who cannot undergo cognitive testing or interview because of severe drowsiness or agitation). The 4AT has a sensitivity of 89.7% and a specificity of 84.1% in the detection of delirium.

 

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Delirium precipitating factors/causes

Environment

Change in environment

Loss of visual or hearing aid

Inappropriate noise or lighting

Immobility

Poor sleep hygiene

Catheters and drips

Falls

Physical restraint.

Fluid and electrolyte abnormality

Hypo/hypernatremia

Hyper/hypocalcaemia

AKI

Dehydration

Neurological illness

Stroke

Seizure

Intracerebral bleeds

Respiratory/cardiovascular

Hypoxia of any cause

Myocardial infarction

Drugs

Alcohol or sedative withdrawal

Sedative hypnotics

Opioids

Anti-parkinsonian medications

Antidepressants

Anticonvulsants

Steroids

Anticholinergic medication

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Delirium precipitating factors

Infections

Of any cause

Surgery

 

Urinary and faecal retention

 

Metabolic

Hypo/hyperthyroidism

Hypo/hyperglycaemia

Liver failure

B12/folate/thiamine deficiency

Pain

 

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Delirium precipitating factors

A memory aid for delirium precipitants-think DELIRIUM 

D

rugs (withdrawal, toxicity)/

D

ehydration

E

lectrolyte imbalance

L

evel of pain

I

nfection/Inflammation (post op)

R

espiratory failure

I

mpaction of faeces

U

rinary retention

M

etabolic disorder (liver/renal failure, hypoglycaemia)

M

yocardial infarction

 

NB in 30% of cases no cause found. 

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Delirium investigations

The following are almost always indicated in investigation of acute confusion in order to identify an underlying cause:FBC

U&E

Calcium

B12 and Folate

TSH

Glucose

ECG

Urine analysis.

CT/MRI brain

Arterial blood gases

Blood cultures

EEG

LP

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Delirium non pharmacological treatment

Do’s

Don’ts

Correct hypoxia

Remain vigilant for infection

Correct dehydration

Involve dieticians

Treat pain and use not verbal scoring systems

Involve family in care

Document well

Involve mental health teams if psychotic symptoms present

Ensure patient is observed at arms length and consider extra staffing

Engage patient in meaningful activities

Repeated orientation

Ensure patient has sensory aids

Ensure good lighting levels in the day.

Use non-confrontational and empathic de-escalation techniques

Delay diagnosis

Catheterise unnecessarily

Use IV lines unnecessarily

Order unnecessary tests

Disturb sleep for

obs

/medication rounds

Subject patient to unnecessary bay or ward moves

Turn lights on unnecessarily at night

Use medication unless other interventions have failed.

Use high doses of medications for elderly patients.

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Delirium pharmacological treatment

NICE 2010: haloperidol or olanzapine in low doses for 1 week or less.Use antipsychotics with caution in Parkinson’s or dementia in Lewy body.

Lorazepam, promethazine, risperidone.

procyclidine

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Differentiating dementia and delirium

Dementia Delirium

Chronic slow decline acute onset hrs/days

Functional decline previously functional

Clear consciousness impaired

Non reversible

reversible

Usually non fluctuant fluctuates

Both may present with delusions and hallucinations

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Clinical scenarios

Winston Churchill 1874-1965 History documented by Lord Moran

?Very early symptoms

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1944 Decrease in concentration, quarrelsome and irritable, argued with key allies

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1949 CVA Right hand and arm weakness, good physical recovery, no publicity

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1950/1951 2 TIAs

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1951 Returned as PM, deterioration evident in mental functioning, documents were condensed to a single paragraph, poor memory for world events

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1953 CVA during a state banquet. Good physical

recovery, speeches rehearsed many times

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1954 Confused over names and places

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1955 Resigned

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1965 Died immobile, with severe dementia

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Clinical scenarios

Al is a 76- year-old male, who has been in the hospital for one day. Al has not had any unusual behaviours, but his family reports that slowly over the course of the past year, he has been getting gradually more forgetful. Al has more trouble dressing than he did last year. Al seems to have more trouble finding the right words to say than he did a year ago. Al gets confused more often than last year about where he is going. None of these changes happened all at once, but Al seems to be slowly getting more confused in his memory and thinking. Vital signs, physical examination and ECG have been normal, and all lab values were within normal limits.

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Clinical scenarios

Betty is an 80-year-old female who has been the hospital for two days. Betty has been doing fine, and has no memory complaints. One morning, Betty does not want to get out of bed. Betty does not seem to be interested in food and seems very slowed down. She appears sleepier than usual, and is disoriented to time, place, and mistakes her nurse for one of her relatives. Betty does not seem to be paying much attention when you talk to her. Over the next few days, Betty spends a lot of time just lying in bed and staring into space. According to the family, she did not have a history of depression, sadness, or feeling blue.

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Clinical scenarios

Diane is an 83-year-old female who has been in the hospital one day. According to her family, Diane has had increasing memory problems over the past year, and problems getting lost while driving to a local restaurant where she has been many times. She has more difficulty finding the right name for things. She has also experienced increased difficulty in completing daily ADL’s. In the morning, you go in to check her vital signs and suddenly she is more confused. She tells you to stay away and tries to punch you. This is not her usual behaviour at home. She accuses you of trying to kill her and steal her belongings. She is disoriented to time and place, and does not recognize you as her nurse. You leave the room, and you hear her talking to herself and moving things around in the room. You return to check on her and find that she has pulled out her IV.

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Questions??

fionamcdowall@nhs.net