Transcript Dementia and Delirium Presentation - 294 KB

Dementia: a Risk Factor
for Delirium
Linda DeCherrie, MD
Geriatrics Fellow
Brookdale Department of Geriatrics and
Adult Development
Mount Sinai School of Medicine
April 19, 2004
MKSAP Question:
An 88 yo woman is hospitalized because of a UTI.
She has a history of mild dementia, and her
husband states that her confusion often
worsens at night. She takes no medications at
home. Antibiotic therapy is begun in the
hospital.
Which one of the following measures is most likely
to be effective in avoiding the development of
delirium in this patient in the hospital?
MKSAP Question:
a) Place a foley catheter, restrain the patient physically,
and limit fluids after super.
b) Provide bright illumination in the room at all times,
repeated orientation by her nurses whenever the patient
is awake, and benzodiazepines hypnotics at night as
needed.
c) Reduce ambient noise at night, enable the patient to
move about during the day, and disimpact earwax
d) Reduce ambient noise, encourage family members to
stay with her, and give benzodiazepine hypnotics at
night.
e) Provide visual aids and adaptive equipment for low
vision and bedrails and haloperidol at night.
MKSAP Question:
a) Place a foley catheter, restrain the patient physically,
and limit fluids after super.
b) Provide bright illumination in the room at all times,
repeated orientation by her nurses whenever the patient
is awake, and benzodiazepines hypnotics at night as
needed.
c) Reduce ambient noise at night, enable the patient to
move about during the day, and disimpact earwax
d) Reduce ambient noise, encourage family members to
stay with her, and give benzodiazepine hypnotics at
night.
e) Provide visual aids and adaptive equipment for low
vision and bedrails and haloperidol at night.
Objectives
• Distinguish between dementia and
delirium
• Learn ways to decrease the incidence of
delirium in patients with dementia when
they are admitted to the hospital
• Understand the differential for delirium
Topics Covered
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What is dementia
What is delirium
Who is at risk for delirium
Strategies to reduce the incidence of
delirium
• Differential of delirium
• Treatments of delirium
WHAT IS DEMENTIA?
• An acquired syndrome of decline in memory and
other cognitive functions sufficient to affect daily
life in an alert patient
• Progressive and disabling
• NOT an inherent aspect of aging
• Different from normal cognitive lapses
GRS
What Diseases Cause Dementia?
• Alzheimer’s Disease
• Vascular Dementia
• Frontal Dementia
• Dementia with Lewy Body
• Others: Huntington’s disease, Jakob-Creutzfeld
disease, progressive supranuclear palsy, and
Parkinson’s disease
THE DEMOGRAPHY OF
DEMENTIA
• 4 million in U.S. currently
• 14 million in U.S. by 2050
• 1 in 10 persons aged 65+ and nearly half
of those aged 85+ have dementia
• Life expectancy of 8-10 years after
symptoms begin
GRS
DELIRIUM vs DEMENTIA
Delirium and dementia often occur together in
older hospitalized patients; the distinguishing
signs of delirium are:
• Acute onset
• Cognitive fluctuations over hours or days
• Impaired consciousness and attention
• Altered sleep cycles
GRS
CAM: Confusion Assessment
Method
1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness (Alert, vigilant,
lethargic, stupor, coma)
Diagnosis of delirium requires 1 and 2 and
either 3 or 4
DEPRESSION vs DEMENTIA
The symptoms of depression and dementia often
overlap; patients with primary depression:
• Demonstrate  motivation during cognitive
testing
• Express cognitive complaints that exceed
measured deficits
• Maintain language and motor skills
GRS
Who is at risk for delirium?
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Dementia
Advanced age
Male gender
Poor functional status
Severe Illness
Depression
Sensory Impairment
Fever
History of ETOH use
Pain at rest
Elie M et al. Delirium risk factors in elderly hospitalized patiente. J
Gen Intern Med 1998; 12:204-12.
Case
71 yo male with A fib presents a few day
prior to a revision of THR to switch from
coumadin to heparin.
Patient has no current complaints, THR from
20 years ago “worn out” and causes pain
Had had multiple falls recently
Recently started on memantine for memory
and ditropan for urge incontinence
Case, Cont
PMH:
A fib
CVA – R minimal weakness
OA
Multiple basal cell ca of skin
Case, Cont
Meds:
Acidophilus
Coumadin
Digoxin
Ditropan
Memantine
SH:
Lives with wife
Retired
Ind. ADL’s
Walks with cane
+ tob, 2-3
drinks/day
Case, Cont
PE: 36.9 69 20 98/64
Gen: NAD
Neck: no JVD
Lungs: CTA bilat
CV: irreg irreg nl S1S2
Abd: + NABS, soft, ecchymosis R flank
Ext: No Edema, 2+ DP
Neuro: A&O X3, strength 5/5 Left, 5/5 left UE, 4/5
left LE
Tests for Dementia that can be
Performed Inpatient
• Orientation questions
• MMSE
• Clock drawing
Why is it important to recognize
delirium?
• Symptom of an unrecognized medical problem
(cause of delirium)
• Increases length of stay
• Increases readmission rates
• At risk for other iatrogenic problems (ie falls,
pressure ulcers)
• Prognosis for family: Only 5% of delirium resolved at
discharge, 62% still have symptoms at 6 months
Levkoff, SE et al. Delirium: The occurrence
and persistence of symptoms among elderly
hospitalized patients. Arch Intern Med 1992;
52 (2) 334-76
How can we avoid inpatient
delirium?
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Orientation strategies
Maintain day/night schedule
Avoid restraints
Avoid sedative/hypnotics
Ensure assistive devices are working
(eyes and ears)
• Avoid immobility
• Avoid dehydration
Multicomponent Intervention to
Prevent Delirium
Inouye, S. K. et al. N Engl J Med 1999;340:669-676
• Interventions on 6 risk factors for delirium
• 852 patients enrolled, half in treatment
group, half in usual care
• Risk–factor intervention reduced number
of episodes of delirium and deceased the
length of episodes of delirium
Multicomponent Intervention
to Prevent Delirium
• Orientation: 1-3 times a day
– Orientation board with team names and
schedule
– Communication to orient
– Cognitively stimulating activities: word games,
current events
Multicomponent Intervention
to Prevent Delirium
• Sleep
– Non pharmacologic sleep protocol: warm
drink, relaxation music, back-massage
– Sleep enhancement protocol: decreased
noise on unit (d/c night time floor washes, etc)
Multicomponent Intervention
to Prevent Delirium
• Immobility
– Ambulation or ROM exercises TID
– Minimize use of restrictive equipment (bladder
catheters, IV’s)
Multicomponent Intervention
to Prevent Delirium
• Visual impairment
– Visual aids (glasses magnifying glass)
– Adaptive equipment (call bells with florescent
tape, large key pads on telephone)
Multicomponent Intervention
to Prevent Delirium
• Hearing impairment
– Portable amplifying equipment
– Earwax removal
Multicomponent Intervention
to Prevent Delirium
• Dehydration
(BUN/Cr ratio> 18)
– Encourage oral intake
Differential for Delirium
C-Cognitive deficit
O-Organ dysfunction (lung, heart, liver, kidney)
N-Neuro (SZ, ICP)
F-Fever/infection, fecal impaction
U-Urinary retention/UTI
S-Sensory impairment (eyes/ears)
E-EtOH, endocrine, electrolytes
D-Drugs – narcotics, anticholinergics, antiinflammatory etc.
Differential for Delirium
D-Drugs, dementia, depression
E-Endocrine/electrolytes, Environment
L-Liver
I-Intracranial (bleed, mass, hydrocephalus)
R-Restriction in senses/mobility
I-Infection/Impaction
U-UTI/uremia
M-Myocardial infarction, hypoxemia
Treatment of Delirium
• Determine and treat underlying cause
• Used non pharmacologic strategies (the
ones used for prevention)
• Medication
Treatment of Delirium
• Medication (agitation or aggression)
– Haloperidol – high potency antipsychotic
• Advantages: low cost, multiple routes
• Disadvantages: EPS, TD
• Dose: 0.5mg - 2mg PO, IM/IV twice as potent
– Resperidone (risperdol)
• Advantages: Less EPS
• Disadvantages: Orthostasis, EPS at high doses,
recent concern with stroke
• Dose:0.25-1mg QD
Treatment of Delirium
– Olanzapine (Zyprexa)
• Advantages: Less EPS
• Disadvantages: sedation, weight gain, possible
association with diabetes
• Dose: 2.5-10mg QD
– Benzodiazepines – for delirium cause by
ETOH withdrawl
• Disadvantage – can cause delirium
• Dose: Ativan 0.5 – 2mg q3-4 hours
Summary
• Dementia is common in older adults
but is NOT an inherent part of aging
• Delirium is common when patients with
dementia are admitted to the hospital
Summary, Cont
• Consider a broad differential for delirium
• Treatment of delirium starts with determining
underlying cause and correcting it
• Other treatments include the nonpharmacologic measures and if absolutely
necessary, medications
MKSAP Question 2:
An 88 yo man is hospitalized for pneumonia
and poor nutritional intake. He has no
known family members and no medical
records. He is tachypneic, tachycardic,
febrile, and coughing continuously. PE
and CXR confirm lobar pneumonia, and
antibiotic therapy is begun. The fever
resolves promptly and leukocytosos
resolves by the third day of treatment.
MKSAP Question 2:
His vital signs return to normal, and the
cough nears resolution. He is not treated
with any other medications.
On the sixth hospital day, the patient
becomes inattentive, confused, and
drowsy with apparent hallucinations and
fluctuating mental status. His vital signs
remain normal.
MKSAP Question 2:
Which one of the following is the most likely
cause of this patient’s delirium?
(a) Hyponatremia
(b) Meningitis
(c) Alcohol abstinence syndrome
(d) Hypoxemia
(e) Drug reaction
MKSAP Question 2:
Which one of the following is the most likely
cause of this patient’s delirium?
(a) Hyponatremia