Confusion in the older adult: delirium and dementia

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Open education forum presentation by Dr. Christine Tomkinson on care of the older confused adult. Uploaded with permission, free to distribute.

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  • CONFUSION = problem with coherent thinking; depressed sensorium and reduced attention span

    EEG studies – disturbance of global cortical function
    Acetylcholine plays a key role (anticholinergic drugs often cause delirium; medical conditions preceding delirium, such as hypoxia/hypoglycemia/thiamine deficiency, decrease ACh synthesis in CNS)
  • Up to 50% mortality 1 yr after delirium
  • Hypoactive vs Hyperactive

    Clothes picking/picking at air
  • Anticholinergic effects (atropine) can also be from antipsychotics, antidepressants (TCAs), antihistamines, antispasmodics, antimuscarinics for bladder overactivity
  • Systemic organ failure – Cardiac failure, Hematologic
  • Underlying brain disease present in approx 50% of older adults with delirium
  • Decline in cognition involving one or more domains

    Deficits cause significant impairment in social/occupational function

    Aphasia = disturbance in expression or comprehension of language
    Apraxia = inability to perform learned movements/skills (not due to incoordination, sensory impairment or weakness) – can’t brush teeth/brush hair/how to dress/walking
    Agnosia = inability to recognize (eg objects/faces/sounds/smells)
  • Little data from the Middle East, Africa, Latin America, Eastern Europe

    **Projected rise largest in low-to-middle income countries – in Middle East and North African countries, projected increase of 125%
  • Although usually over age 60, small % have early onset
    In patients with DS, usually in 40s
  • AD – inability to learn new tasks
  • LBD – early deficits in attention and visuospatial function with memory affected later on
    - parkinsonian features more often bilateral and less severe than in idiopathic PD
  • NPH – classic triad of gait disturbance (apraxia/magnetic gait), cognitive impairment, and urinary incontinence; enlarged ventricles without high CSF pressure or blockage
  • Holiff J, White M, and Wilson KR. Psychiatry. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc, Toronto 2011. p.17-19.
  • Confusion in the older adult: delirium and dementia

    1. 1. D r . C h r i s t i n e T o m k i n s o n , B S c B M B S A d u l t N e u r o l o g y R e s i d e n t , M c M a s t e r U n i v e r s i t y O n t a r i o , C a n a d a Confusion in the Older Adult
    2. 2. 76 yr old woman with confusion…  Focused Medical History  Duration?  Constant or fluctuating?  ROS – fever, malaise, cough, dysuria, recent trauma
    3. 3. 76 yr old woman with confusion…  Past Medical History  Previous similar episodes?  Known dementia diagnosis?  If so, what’s different today?
    4. 4. 76 yr old woman with confusion…  Medications  List of medications; any recent changes?  Who controls meds and how are they given (blister pack, etc)  Any concerns with med administration?  Look at meds – more/less than expected?
    5. 5. 76 yr old woman with confusion…  Social History  Who lives with her?  Recently widowed?  Social outlets?  Diet, alcohol use
    6. 6. Delirium  Disturbance in consciousness, with reduced ability to focus, sustain, or shift attention  Change in cognition or development of a perceptual disturbance  Disturbance develops over short period of time (hrs to days)  Fluctuates during course of day  Caused by a medical condition, substance intoxication or medication side effect
    7. 7. Why do we care?  10-15% prevalence in general medical/surgical in patients  Approx 30% of older patients during a hospital stay  60-70% in ICU  80-90% palliative care  Increased length of hospital stay, institutional discharge, mortality
    8. 8. Clinical Features  D – Disordered thinking  E – Euphoria, Emotions (fearful, depressed, angry)  L – Language impaired (dysarthia, dysnomia)  I – Illusions, delusions, hallucinations  R – Reversal of sleep-wake cycles  I – Inattention/Distractible  U – Unaware and disoriented  M – Memory deficits
    9. 9. Causes of Delirium - DIMS  Drugs  New medications, Interactions  Overdose/Withdrawal  Side effects **Anticholingerics  Poisons
    10. 10. Causes of Delirium - DIMS  Infectious/Inflammatory  Sepsis  Meningitis/Encephalitis  UTI/Pneumonia/Cellulitis
    11. 11. Causes of Delirium - DIMS  Metabolic  Electrolyte disturbance  Hyper/Hypo-glycemia  Hypercarbia  Hypoxemia  Endocrine – Thyroid, Parathyroid, Pituitary, Adrenal  Systemic organ failure – Liver/Renal  Nutritional – Wernicke’s (Thiamine), B12, Folate
    12. 12. Causes of Delirium - DIMS  Structural  Head injury – SAH, SDH  Stroke, Seizure  Space occupying lesion – Neoplasm, Abscess
    13. 13. Risk Factors Predisposing Factors Precipitating Factors Underlying brain diseases (dementias) Polypharmacy Advanced age Infection Sensory impairment Dehydration Immobility Malnutrition Catheter use Hospitalization/Nursing home
    14. 14. Dementia  Development of multiple cognitive deficits  Memory impairment  At least one of:  Aphasia  Apraxia  Agnosia  Disturbance in executive function  Gradual onset and progressive decline
    15. 15. Epidemiology  Estimated 35.6 million people worldwide (2010)  Total projected to double every 20 years  In Middle East and North African countries, projected increase of 125% Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization report. Alzheimers Res Ther, 2012. 4(5)
    16. 16. Epidemiology  Approx 15% over age 65  Incidence doubles every 10 years after 60  50% prevalence over age 90  Prevalence increased in Down Syndrome and head injury (AD)
    17. 17. Types of Dementia  Alzheimer’s Disease – 60-80%  STM loss (anterograde amnesia)  Loss of visuospatial skills, insight, executive functioning, apraxia  Vascular Dementia (multi-infarct) – 10-20%  Abrupt onset and stepwise deterioration  Focal findings/Deficits specific to area affected  May have vascular risk factors or stroke history  Mixed
    18. 18. Types of Dementia  Frontotemporal Dementia – 10%  Disinhibition, socially inappropriate  Emotional lability  Progressive expressive aphasia  Memory preserved  Lewy Body Dementia – 15-25%  Fluctuating cognition/attention with progressive decline  Visual hallucinations  Parkinsonism  Parkinson’s related Dementia
    19. 19. Reversible Dementia  Normal Pressure hydrocephalus  Vitamin deficiencies  Wernicke-Korsakoff’s (Thiamine – EtOH)  B12, Folate  Medications  Thyroid dysfunction  Hypo/Hyper-glycemia  Cortisol  Depression  Heavy metals
    20. 20. So what should you check?  Collateral history from family member  Vital signs  Temperature  Glucose  SpO2  GEMS Diamond
    21. 21. Management of a Confused Adult  Well-lit, quiet room  Get down to the patient’s level  Hearing aids/Glasses  Reverse stethoscope if needed  Talk slowly, clearly and use plain language
    22. 22. Management of a Confused Adult  Give them time to process questions  Orient and re-orient; use family members  Avoid restraints, catheters, lines  Stop unnecessary meds  Treat underlying causes
    23. 23. References Atia M, Rastin T, and Scott C. Neurology. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc., Toronto 2011. p.10-15. VIHA. CAM v3 Delirium in the older person: a medical emergency. www.viha.ca/mhas/resources/delirium/ (Accessed June 30,2014) Francis J and Young GB. Diagnosis of delirium and confusional states. In: UpToDate, Wilterdink JL (Ed), UpToDate, Waltham, MA. (Accessed June 26, 2014). Harrington, C.J. and K. Vardi, Delirium: presentation, epidemiology, and diagnostic evaluation (part 1). R I Med J (2013), 2014. 97(6): p. 18-23. Hake AM and Farlow MR. Clinical features and diagnosis of dementia with Lewy bodies. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed July 1, 2014). Holiff J, White M, and Wilson KR. Psychiatry. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc, Toronto 2011. p.17-19. Shadien MF and Larson EB. Risk factors for cognitive decline and dementia. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed June 30,2014). World Health Organization. Dementia: A public health priority. WHO Press, Geneva 2012. Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization report. Alzheimers Res Ther, 2012. 4(5): p. 40. Wright CB. Etiology, clinical manifestations, and diagnosis of vascular dementia. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed July 1, 2014).

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