RECOGNITION AND MANAGEMENT OF DEMENTIA IN THE ACUTE CARE SETTING

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1 RECOGNITION AND MANAGEMENT OF DEMENTIA IN THE ACUTE CARE SETTING Alex Hishaw, MD Department of Neurology University of Arizona Objectives: Recognize the impact of history and presentation on the diagnosis of Alzheimer's Review the differential of cognitive decline Describe the time frame for follow up on cognitive decline DISCLOSURE OF COMMERCIAL SUPPORT Alex Hishaw, MD does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. 1

2 G. Alexander Hishaw, MD Assistant Professor of Neurology & Psychiatry University of Arizona Polytrauma, Southern Arizona VA Medical Center Disclosures Board member for the Arizona Governor s Council on Spinal and Brain Injury Medical Advisor for BioDirection The best approach to recognizing dementia in the acute setting is to reevaluate the patient when the setting is no longer acute. 2

3 Differential of Confusion Infection Encephalitis, meningitis, syphilis, HIV, sepsis Withdrawal Alcohol, barbiturates, sedative-hypnotics Acute Metabolic Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure Trauma Closed-head injury, heat stroke, postoperative, severe burns CNS Pathology Abscess, hemorrhage, hydrocephalus, subdural hematoma, seizures, stroke, infection, tumors, metastases, vasculitis Hypoxia Anemia, carbon monoxide poisoning, hypotension, pulmonary or cardiac Deficiencies Vitamin B12, folate, niacin, thiamin Endocrinopathies Hyper/hypoadrenocorticism, hyper/hypoglycemia, myxedema, hyperparathyroidism Acute Vascular Hypertensive encephalopathy, stroke, arrythmia, shock Toxins or Drugs Medications, illicit drugs, pesticides, solvents Heavy Metals Lead, manganese, mercury Defining Delirium An acute confusional state marked by prominent alterations in perception and consciousness and associated with vivid hallucinations, delusions, heightened alertness and agitation, hyperactivity of psychomotor and autonomic functions, insomnia, a tendency to convulse and intense emotional disturbances Delirium is referred to by a variety of other names Acute confusional state, acute brain syndrome, metabolic encephalopathy, toxic psychosis, and acute brain failure 3

4 Defining Delirium A reversible disorder whose hallmarks are confusion and an altered level of consciousness Level of arousal Level of arousal Mildly reduced wakefulness or awareness 4

5 Level of arousal mildly to moderately reduced alertness with lessened interest in the environment, drowsiness while awake, and increased sleep Level of arousal condition of deep sleep or behaviorally similar unresponsiveness from which the subject can be aroused only by vigorous and repeated stimuli Level of arousal state of unarousable psychologic unresponsiveness no psychologically understandable response to external stimulus or inner need 5

6 Level of arousal eyes open spontaneously, a sleep-wake cycle exists, pt is capable of maintaining normal levels of blood pressure and respiratory control, yet they show no discrete localizing motor response and neither offer comprehensible words nor obey any verbal commands Guess the level of arousal Guess the level of arousal 6

7 Guess the level of arousal Guess the level of arousal Level of arousal Hyperactive state and agitation 7

8 Confusion Three domains (attention, orientation, and memory) are typically impaired in delirious patients Attention- difficulty maintaining or shifting focus Orientation- time then place then person Memory- partial or complete amnesia for the period of delirium can occur Attention Testing Digit span Serial calculations Spelling WORLD backwards Months backwards, days of week backwards Attention Anatomy Interactions between the frontal and parietal lobes along with their interaction on the thalamus give conscious volition to attention Vigilance activates Brodmann s areas 8,9,44,46 and 40 Divided attention activates Brodmann s area 46 The limbic system and emotion play a part in motivation of attention 8

9 Memory Memory in its simplest form refers to the ability of the brain to store and retrieve information Memory First stage immediate memory span amount of information a subject can keep in conscious awareness without active memorization disorders of attention may affect digit span very focal lesions of the superior frontal neocortex, affecting Brodmann s areas 8 and 9 Memory Second stage short-term or recent memory ability to register and recall specific items after a delay of minutes or hours declarative or episodic memory requires the function of the hippocampus and parahippocampus areas 9

10 Memory Declarative or Explicit Memory Story Memory Nondeclarative or Implicit Memory Subject has no conscious awareness Motor memory Know how rather than know that Storage and retrieval do not involve the hippocampal system Memory Third stage Long term memory or remote memory Resists the effects of medial temporal damage; once memory is well stored, it can be retrieved without use of the hippocampal system Bedside Mental Status Exam General Language Appearance Spontaneous speech Affect Repetition, reading and writing Eye contact Naming Orientation Math Attention Left/Right relations Digit Span Finger gnosis Months of the Year or Days of the Week Serial subtractions Memory Praxis New learning Eyes- Buccofacial- Limb- Axial Recent Remote Frontal Systems Visuospatial Go- No Go Cancellation test Alternating sequences Cookie Theft Trails A/B Constructions List generation Faces Abstract Reasoning Prososdy What s the difference between a lie and a mistake? Receptive What do we mean when we say a person is blue? Expressive If you found a two year-old child alone and crying in front of the hospital, what should you do? 10

11 Diagnostic Evaluation First line- electrolytes, complete blood cell count, erythrocyte sedimentation rate, liver and thyroid function tests, toxicology screen, syphilis serology, blood cultures, urine culture, chest x-ray and electrocardiogram Second line- neuroimaging, cerebrospinal fluid analysis, electroencephalogram, human immunodeficiency virus antibody titer, cardiac enzymes, blood gases, and autoantibody screen Defining Dementia Syndrome characterized by a deterioration of function in multiple cognitive/intellectual areas in an individual who has previously possessed a normal mind with little or no disturbance of perception of consciousness Etiology of Dementia 11

12 Dementia of The Alzheimer s type A decline in memory, as well as impairment of at least one other domain of cognitive function Aphasia Apraxia Agnosia Executive dysfunction Must be severe enough to impact level of functioning Dementia of the Alzheimer s type Incidence increases with age Affects 15-20% of individuals after the age of 65 years Affects up to 45% of individuals after the age of 80 12

13 Dementia of the Alzheimer s Type estimated to be by far the most common form of dementia in the United States currently afflicting as many as 4.5 million mainly elderly individuals Dementia of the Alzheimer s Type The major risk factor for Alzheimer's disease is aging The second major risk factor is family history Dementia of the Alzheimer s Type A combined clinical and neuropathological diagnosis that can only be made definitively by brain biopsy or at postmortem examination to have the histopathological changes of DAT 13

14 Dementia of the Alzheimer s Type Neuritic Plaques Neurofibrillary tangles Dementia of the Alzheimer s Type atrophy starts in the entorhinal cortex and hippocampus, and as the illness worsens clinically, loss of brain volume increases and spreads more globally to involve most areas of the cortex except the occipital poles 14

15 Dementia of the Alzheimer s Type Mild Stages Begins insidiously Subtle difficulties in recent memory are almost always the first sign Dementia of the Alzheimer s Type Moderate stages Usually after several years of cognitive impairment, a fluent type of aphasia begins, characterized by difficulty naming objects or choosing the right word to express an idea Dementia of the Alzheimer s Type Severe Stages patients develop disrupted sleep/wake cycles, begin to wander, have episodes of irritability and motor hyperactivity (Sundowning) Lose ability to attend to personal care needs such as dressing, feeding, and personal hygiene 15

16 Incidence increases with age Affects 15-20% of individuals after the age of 65 years Affects up to 45% of individuals after the age of 80 Frequency of Clinical Features of Delirium Contrasted with Dementia Feature Delirium Dementia Impaired memory Impaired thinking Impaired judgment Clouding of consciousness Major attention deficits Fluctuation over course of day Disorientation Vivid perceptual disturbances ++ + Incoherent speech ++ + Disrupted sleep-wake cycle ++ + Nocturnal exacerbation ++ + Insight ++ + Acute or subacute onset ++ - Risk factors for Delirium Elderly age Children Preexisting brain damage (dementia, cerebrovascular disease, tumor, head injury) History of delirium Drug dependency Acquired immunodeficiency Cardiac surgery Burns Malnutrition 16

17 Diagnostic Evaluation CSF tau protein and β- amyloid are available but their use is not always helpful EEG is not routine due to the overlap in patterns among different dementias SPECT and PET Neuropsychological testing The value of APOE genotyping is also unknown Diagnostic Evaluation CSF tau protein and β- amyloid are available but their use is not always helpful Decreased levels of CSF B-amyloid and elevated levels of CSF Phosphorylated tau seems to be positive for Alzheimer s as well as people who are likely to develop Alzheimer s Diagnostic Evaluation EEG is not routine due to the overlap in patterns among different dementias 17

18 Diagnostic Evaluation SPECT and PET Shows areas of decreased metabolism or blood flow Diagnostic Evaluation SPECT and PET Shows areas of decreased metabolism or blood flow Amyloid imaging PiB compound Florbetapir Florbetaben Flumetamol F-AZD4694 Diagnostic Evaluation Mutations in the genes that encode β- amyloid precursor protein, presenilin-1 and presenilin-2 cause the rare early-onset form of familial Alzheimer s Disease this increases the β-amyloid 42 levels less than 1% of Alzheimer s Disease Apolipoprotein E is seen in early- and lateonset Alzheimer s Disease this increases the β-amyloid deposition 42-68% of late-onset Alzheimer s Disease patients do not have Apo E4 18

19 Approach Minimize medication use Avoid Anticholinergic medications Benzodiazepines Opiates Use Antipsychotics at a minimum dose Haloperidol, risperidone, quetiapine Drugs that can cause delirium Approach Identify and treat the underlying cause Consider ancillary testing as available Referral for outpatient evaluation is reasonable given the increased risk of dementia Give the individual time to recover Beware the patient who has a delirium and dementia 19

20 The END 20