Dementia and Delirium

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1 Dementia and Delirium LPT Gondar Mental Health Group

2 Dementia and Delirium WTINP Chapter 4.6

3 Introduction - areas to be covered Delirium Definition and causes Clinical features Management principles Dementia Definition Common causes and epidemiology Clinical features and assessment Treatment and other management issues

4 Delirium - definition Global impairment of cognition; disturbances of attention and conscious level; abnormal psychomotor behaviour and affect; disturbed sleep-wake cycle Onset is usually acute (hours/days) All symptoms fluctuate during daytime and are typically worst at night Patients may be predominantly hypo- or hyperactive or switch between the two states

5 Delirium - impaired consciousness WTINP-Page 13 Box 1.8 Typically, like other features, will fluctuate Continuum from full alertness through to unconsciousness Earliest stage = clouding of consciousness, characterised by attentional deficits

6 Delirium - perceptual disturbance Usually in the visual modality Likely to fluctuate on continuum from normal through various stages of perceptual distortion to hallucination Visual hallucinations when present tend to be fragmentary and/or transient - persistent wellformed hallucinations less characteristic

7 Prevalence of confusion amongst acute medical admissions 2000 consecutive medical admissions age 55 yrs or older - Erkinjuntti et al % 4% 11% 80% (Community prevalence approx %) Cognitively intact Dementia only Dementia+delirium Delirium

8 Causes of delirium Medication Metabolic Infection CVS CNS Other 5 0 Rudberg 1997 (n=63) George 1997 (n=217)

9 Drug induced delirium Psychotropic drugs Antidepressants Antipsychotics Benzodiazepines Antiparkinsonian drugs Anticholinergic drugs Opiates Diuretics (recreational drug intoxication and withdrawl)

10 Outcome of delirium Just because delirium is a transient mental disorder, it does not follow that all patients get better Prognosis of acutely ill patients is poorer in the presence of delirium: Increased mortality at 1 year (OR 2.3) Institutionalisation by 1 year (OR 4.5) Readmission within 1 year (OR 2.1)

11 Diagnosis of delirium Look for the clinical features especially fluctuating symptoms Assess cognitive function Brief tests e.g. AMT or clock-drawing Identify the causative factor(s) Especially important when no obvious physical presenting problem

12 Delirium - management Treatment of the underlying condition General supportive measures e.g. Maintaining hydration and nutrition Attention to physical and human environment Control of distressing physical symptoms Symptomatic treatment of disturbed behaviour, if unavoidable

13 Diagnostic guidelines - dementia WTINP Page 15 Box 1.10 Decline in both memory and thinking sufficient to impair personal ADLs Problems with the processing of incoming information - problems with maintaining and directing attention Clear consciousness Above syndrome present for >= 6 months

14 Why is dementia different to other disabling conditions? It is common It does not confer a static disability i.e. it is usually progressive It is very stressful for carers and the patient s family Those who are most dependent and vulnerable often have the least awareness of their disabilities

15 The common causes of dementia Alzheimer s disease(ad) c.60% Vascular dementia (VaD) - not necessarily multiinfarct disease c.15% Lewy body dementia (DLB) c.10-15% Other - including... Other neurodegenerative disease; CNS neoplasia, toxicity, inflammatory disease and infections; vitamin deficiency states; hypothyroidism etc etc

16 Pathology of Alzheimer's Disease Shrunken brain with widened sulci and enlarged ventricles Histologically some cell loss especially in 3 outer cortical layers Plaques throughout cortical and subcortical grey matter- core of amyloid Neurofibrillary tangles

17 % Dementia epidemiology Prevalence and incidence is very highly agedependent but fairly similar in different countries Cross sectional prevalence: all-cause dementia Age - years

18 Course Cognitive impairment - clinical Early pattern of cognitve deficits Neurological findings features and differential diagnosis AD DLB VaD Delirium Depression Gradual progression Memory and attentional deficits Minimal in early stages; paratonia, myoclonus etc later Marked fluctuations Memory and attentional (±frontal) deficits Spontaneous or neurolepticinduced Parkinsonism Stepwise decline Patchy and variable Variable: may be pyramidal tract signs Acute onset and fluctuation Attentional deficits Variable: depending upon underlying cause Episodic ± identifiable antecedents Impaired attention and concentration None Perceptual abnormality Disturbance of affect

19 Presentation of dementia - early features With AD and several other dementias, circumscribed memory disorder may be the earliest feature Some level of insight and awareness may be present Symptoms not necessarily disabling (so strictly, not dementia)

20 Presentation of dementia - middle-stage features More pervasive and severe memory disorder, often with confabulation Disturbance of language and other cortical cognitive functions Alterations in personality, affect and behaviour Other non-cognitive features e.g. psychotic symptoms

21 Presentation of dementia - late features Profound impairments of memory, attention and other cognitive functions Language deficits may have become very pronounced - dysphasia Major behavioural abnormalities (+ve and -ve) Neurological disturbance and physical frailty

22 Diagnostic assessment - how accurate can we be? Identifying the presence of dementia Simple cognitive screening tests will not miss many cases of dementia Identifying specific disorders By use of standardised diagnostic criteria (e.g. NINCDS criteria) - specificity of 90% can be attained for AD Compares favourably with other medical/neurological disorders (e.g. Parkinson s disease - <75%)

23 Other aspects of assessment Identification of related psychiatric morbidity/non-cognitive symptoms Identification of unrelated but clinically relevant co-morbidity (esp. physical) Assessment of disability and personal functioning Assessment of social circumstances and carer s needs

24 Assessment I - establishing the presence of dementia Two main requirements: Systematic cognitive assessment Informant history - onset and course of the problem

25 Cognitive screening instruments Blessed IMC test and derivatives Hodkinson mental test (< 7/10) CAPE information/orientation test (<8/12) Mini mental state examination (< 24/30) Clock drawing and several others ANYTHING IS BETTER THAN NOTHING!

26 Assessment II - establishing underlying diagnoses More detailed cognitive assessment More informant history - course of illness, associated features etc Comprehensive mental state examination Physical examination Simple physical investigations e.g. CXR, ECG, blood tests Complex physical investigations brain imaging

27 Dementia screens and the role of basic investigations Simple investigations such as blood tests, x-rays, ECG etc May have role in detecting reversible dementias e.g. B12 deficiency, hypothyroidism Main function however is to identify exacerbating comorbid conditions

28 The changing role of complex investigations Previously CT was the main neuroimaging modality Mainly useful for exclusion of certain (uncommon) causes of dementia

29 The changing role of complex MRI now investigation of choice in all cases subject to availability and patient-tolerance Much greater utility for contributing to diagnosis for the common dementias investigations

30 General principles of management of dementia Traditionally: Symptomatic treatments and interventions for the patient Support for carer Now: Disease-specific drug treatments, which in turn may demand more complex diagnostic assessments

31 Drug treatment of AD - cholinesterase inhibitors Predicated on the cholinergic hypothesis in AD Donepezil and rivastigmine and galantamine - licensed for the treatment of mild to moderate probable AD Broadly similar efficacy Who will respond? What constitutes a good response? How long should treatment continue?

32 Provided by The Leicester Gondar Link Collaborative Teaching Project This work is licensed under a Creative Commons Attribution-NonCommercial- NoDerivs 3.0 Unported License.

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