Dementia

vs.
Delirium
Margaret Kea Cassada, M.D.
Outline
Defining the terms
Dementia and subtypes
prevalence rates
clinical pearls
Delirium
predisposing factors
mnemonic
Compare and contrast
Cases
Q&A
Dementia and Delirium
Everyone confuses these terms!

This is significant because of our aging

population:
By 2030- the elderly population will
double to > 70 million
Time bomb of morbidity!
Dementia
A serious loss of cognitive ability in a
previously unimpaired person

Degenerative, traumatic, or infectious

ADAMS study from Duke university:

prevalence of all dementias in persons >71 is 14%, increases
dramatically over age 90
All Dementias
 Alzheimer’s disease- 69.9%
 Vascular dementia- 17.4%
 All others- 12.7%
 Lewy body dementia
 Parkinson’s disease
 Normal pressure hydrocephalus
 Fronto-temporal dementias
 ETOH, trauma, HIV, etc.
Predictors of Dementia
 Increasing age
 Lower educational achievement
 APOE4 alleles
Clinical Pearls- Alzheimer’s
 Slow, inexorable progression; fairly steady
 6-12 year course
 Amnesia
 Aphasia
 Apraxia
 Agnosia
Clinical Pearls- Vascular dementia
 “Stair step” decline
 Defined periods of stability
 History of diabetes and hypertension
 Typical findings on radiologic studies
 Generally preserved speech and social
skills
Delirium
A) Disturbance of consciousness with reduced ability to focus,
sustain, or shift attention
B) A change in cognition or development of a perceptual
disturbance that is not better accounted for by a preexisting,
established, or evolving dementia
C) The disturbance develops over a short period of time
(usually hours to days) and tends to fluctuate over the
course of a day
D) Evidence from the history, physical exam, or lab findings
indicate that the disturbance is caused by the direct
physiologic consequences of a general medical condition
Sine Qua Non
Waxing and waning symptoms over the
course of the day
ALWAYS medical
ALWAYS abrupt
Mortality rate 22-76% if untreated or
unrecognized
Can be persistent in vulnerable populations
Risk factors for delirium
 Patient characteristics
 Hospitalized
 Multiple medical issues
 Multiple meds
 Terminal
 Sensory deprivation
 Sleep deprivation
DEELIIIRIUM
 Drugs
 Endocrine
 Epilepsy
 Lung disease
 Infection
 Injury
 Intracranial
 Renal
 Intestinal
 Unstable circulation
 Metabolic/ hepatic
 Treatment
1) Address the underlying
medical issue!
2) SYMPTOMATIC treatment of
the behavioral/psych issues
1) AVOID benzodiazepines
EXCEPT in ETOH or sedative
withdrawal
2) Low dose haloperidol is still the
best studied drug in this situation
 Environmental Interventions
 Provide support and orientation
 Provide an unambiguous
environment- keep stimulation
to a minimum!
 Maintain competence- address
sensory impairment, ambulate
or get patient up routinely
Dementia
vs.
Delirium
vs.
Psychosis
vs.
Depression
Dementia
 Memory impairment
 Disorientation
 Chronic, slow onset, progressive
Delirium
 Fluctuating level of consciousness with
decreased attention
 Disorientation, visual hallucinations,
agitation, apathy, withdrawal, memory
impairment
 Acute onset, remits with correction of
medical condition
Psychotic Disorders
 Deficits in reality testing
 Social withdrawal and apathy
 Slow onset with a prodromal syndrome,
chronic with exacerbations
Depression
 Sadness and loss of interest and pleasure
 Disturbances of sleep, appetite,
concentration, and energy; feeling of
hopelessness, worthlessness, and suicidal
thoughts
 Single or multiple episodes
Case Study 1
 NM 91 yo wm, living at home with 86 yo wife
 Functional in the home until hospitalized for GI
bleed, no etoh, no psych history
 Did well post transfusion, transferred to Swing
bed unit for rehab
 Day 4 of rehab-”sundowning” started, psychiatric
consult requested for visual hallucinations,
fighting care and scratching at his skin
What would you order?
 MRI
 CXR
 WBC
 Vitals
 Physical exam
Treatment of Cellulitis
 Course of vancomycin to treat MRSA
 NM improved, but remained mildly
demented
Case Study 2
 AR 86 yo wf, retired teacher, hearing deficit, lived
at home alone with family in the neighborhood,
nondrinker, no prior psych history
 Became acutely paranoid, up all night calling
daughters to come check her house
 Angry with daughters for not believing her,
daughters distressed over change
 Admitted to geriatric psych unit
What would you order?
 CBC
 Chemistry
 MRI
 Vitals
 CXR
Treatment of Pneumonia
 Treated with Avelox
 Discharged after 4 days
 Attending day treatment and doing well,
although still refuses to wear hearing aid
Case Study 3
 92 yo bm, living alone, very supportive
family, still driving and working in his
garden.
 No psych history, no etoh
 Fell approximately 4 feet off of a ladder
while trying to clean his gutters
 Family found him at home within the hour
acutely disoriented, taken to ER
What would you order?
 MRI
Treatment of concussion
 Admitted to geriatric psych unit, supportive
care and institution of acetylcholinesterase
inhibitor
 After 2 weeks, significantly improved,
returned home with home health
 Fell in the home 3 months later, hip
fracture, nursing home placement
Case Study 4
 Mr.B 86 yo pogressive dementia thought to be
Alzheimer’s over the previous year
 Admitted to assisted living, rapid decline over 6
months
 Primary care MD started muliple different meds-
antidepressants, ache inhibitors, benzodiazepines
 Violent outbursts got worse- begaan attacking
peers and staff
 Physically very robust, but had a 20 year history
of unexplained HA with extensive workup,
unrelieved by occasional opiate use
 Admitted to geriatric psych unit after
breaking a nurse’s finger
 Taken off antidepressant due to agitation
 Deteriorated further- visual hallucinations,
no sleep at all, running into walls
What would you order?
 Vitals
 Laboratory
 Medication review
 Physical exam
Initial treatment
 Taper and discontinue all centrally acting
medications
 Sleep and agitation worsened, movement
disorder appeared- tremors and ataxia
 Trial of anticonvulsant at relatively low dose
 Some mild improvement in sleep
 discharged back to facility
Readmission
 6 total weeks of treatment- all meds
discontinued
 More labs done, all normal
 pt now unable to walk or swallow, labs
begin to show dehydration
 Case reviewed with university colleague
 Week 8- patient died
Human Spongiform Encephalopathy
 Sporadic rate in the general population is
250 per year
 Possibly transmissable through human
derived protein preparations
 Further investigation revealed that the pt
was bitten by a rabid animal in the 1950s,
underwent treatment, and that was the
possible source of infection
Next Steps
 Temporal wasting
 CSF protein data as a predictor of
Alzheimer’s
 Staging of AD- from the Alzheimer’s
Association
Conclusion
 You are as young as your faith, as old as your
doubt; as young as your self-confidence, as old as
your fear; as young as your hope, as old as your
despair.
 Our job as treating professional is to help
overcome those doubts, fears, and despairs- the
best way to do that is to remain faithful, confident,
and hopeful; and to come to this battle armed with
good information!
Sources
 DSM4 TR
 Delirium, Olivia C. Gleason, M.D., in American
Family Physician vol 67 no5 March 2003
 Prevalence of Dementia in the US: the Aging,
Demographics and Memory Study Plassman et.al.
Neuroepidemiology 2007;29:125-132
 www.alz.org