Transcript Delirium and Dementias (Neurocognitive Disorders)

Delirium and Dementias
Salina Chan 2013
Julius Elefante & Brynn Fredricksen 2014
Outline
• Delirium
• Dementia
• Alzheimer’s Disease
• Vascular Dementia
• Lewy Body Dementia
• Parkinson’s Disease
• Management
Delirium
Delirium Epidemiology
• Independent risk factor for mortality
• Increased morbidity, prolonged hospital stays and cognitive deterioration
• Marker for serious & potential life-threatening med problems
• Found in up to 25% of geriatric admissions
• Associated with mortality and morbidity
• Est mortality 22-76%
• Increase risk to staff due to behavioural issues
Delirium: DSM-5 Criteria
1. Disturbance in attention
2. Develops acutely and fluctuates
3. Additional disturbance in cognition
4. Not explained by another evolving neurocognitive disorder
or a severely reduced LOC (e.g., coma)
5. Evidence that it is a direct physiological effect of another
medical condition or is due to multiple etiologies
CLINICAL FEATURES
• Acute onset
• Prodromal phase
• Fluctuating
• Disruption of sleep and
wakefulness
• Emotional disturbance
• Psychomotor disturbance
• Disorders of memory and
orientation
• Disturbance of
consciousness
• Disorders of thought
• Inattention
• Disorders of language
• Perceptual disturbances
CLINICAL VARIANTS
• Hyperactive
• Hypoactive
• Restless/agitated
• Lethargic/drowsy
• Aggressive/hyper-reactive
• Apathetic/inactive
• Autonomic arousal
• Quiet/confused
• 15-47% of cases
• Often escapes diagnosis
• Mixed
• 43-56% of cases
• Often mistaken for
depression
• 19-71% of cases
Exercise 1
• Let’s work out an approach to Delirium
• One slim column “DIMS”
• One fatter column
• Four rows. One letter of DIMS per row
Exercise 1
Drugs
Infectious
Metabolic
Structural
RED FLAGS
Exercise 1
Drugs
•
•
•
Drugs of abuse
Meds – anticholinergics, narcotics, BDZ, steroids, immunosuppresives,
antiparkinsonian agents, cimetidine, antibiotics, Li, MAOIs
Toxins – CO, heavy metals, organophosphates, volatiles,
anticholinesterase
Infectious
•
Pneumonia, UTI, sepsis (Temp >38 or <36, HR >90, RR>20 or PaCO2
<32, WBC >12 or <4 or >10% bands)
Metabolic
•
Acid-base, fluid/electrolyte, hypoglycemia, DKA, hypoperfusion,
hypothermia
Hypertensive encephalopathy, CHF, low PaO2 or high PaCO2, hepatic
failure, renal failure, thyroid, other endocrinopathies
•
Structural
•Infarction, ischemia, neoplasm, stroke
•Other CNS process: vasculitis
RED FLAGS
“WHIMPS”: Withdrawal, Wernicke, hypoglycemia, hypoxia,
hypoperfusion of CNS, hypothermia, hypertensive encephalopathy, ICH,
infection, metabolic, poisons, status epilepticus
Delirium homework
• Take your known delirium mnemonics, such as
IWATCHDEATH and the previous slide and slot
them into DIMS
The Workup
• Suspicion that it is delirium (by definition)
• DIMS differential guides history, physical exam and
laboratory workup
• AIM is two-fold: rule out immediately life-threatening causes, and
defining the cause(s)
• History often obtained from collateral
• Look for the prodrome: increasing moments of confusion
days before, irritability, day/night reversal
Management of Delirium
Multimodal approach in treatment
1.Address underlying cause(s)
• Can often be multifactorial
2.Safety of patient and staff
3.Manage
• Non-pharmacological
• Pharmacological
Delirium: Pharmacological Tx
• Sleep, sleep, sleep! (at night)
• Which of the following should you avoid: melatonin, trazodone,
zopiclone, AP
• AntiΨ meds txn of choice for short-term till delirium subsides
•  mortality/morbidity
• Ensure safety of Pt/Staff
• Aim: to restore Da-Ach imbalance,
• Assumes risk of delirium > risk of AntiΨ
• Haloperidol vs. loxapine
• Risperidone, olanzapine, quetiapine
Capacity vs Competency
• Competency:
• Having the ability to understand and act reasonably
• A legal term
• Decision made by a judge
• Capacity:
• Having the mental ability to make a rational decision based on
understanding and appreciating all relevant info
• Determined by a clinician
Brain – Quickie Review
Neurocognitive Disorder (“Dementia”)
• Major or mild
• Progressive decline of mental functions
• Reasoning
• Memory
• Language
• Problem-solving
• Attention
• Greatly impairs daily function
• Disease seen more in elderly but NOT a normal part of
aging
Dementia Criteria
(DSM-5: Major and Mild Neurocognitive Disorder)
• Cognitive decline from a previous level of performance in > 1
cognitive domains such as:
• complex attention
• executive function
• learning and memory
• language, perceptual-motor
• social cognition
• Based on info from pt, colateral, or clinician and formal testing
• The cognitive deficits interfere with independence in everyday
activities
Specifiers
• Alzheimer’s
• Prion
• FTD
• Parkinson’s
• Lewy body
• Vascular
• Huntington’s
• TBI
• Another medical
condition
• Substance
• Multiple etiologies
• HIV
• Unspecified
Dementia Types
Dementia Prevalence
Alzheimer’s Dementia
• The development of multiple cognitive deficits manifested by
memory impairment AND
• One (or more) of the following cognitive disturbances:
• Aphasia (language disturbance, e.g. word-finding difficulties)
• Apraxia (impaired ability to carry out motor activities despite intact motor
function)
• Agnosia (failure to recognize or identify objects despite intact sensory
function)
• Disturbance in executive functioning (i.e., planning, organizing, sequencing,
abstracting, judgement)
• Gradual onset
• Cognitive Decline
Alzheimer’s Disease
Risk Factors for AD
• Age
• Systolic bp >160 mm Hg
• Total serum chol > 6.5 mmol/L
• Smoking
• Head injury w/ LOC
• Genetic risk factors/family hx late vs early onset
Alzheimer’s Disease
Vascular Dementias
• Step-wise decline
Vascular Dementia Presentation
• Confusion, restlessness,
agitation
• Reduced ability to organize
thoughts/actions, e.g. difficulty
deciding what to do next
• Attention/concentration
difficulties
• Memory and speech/language
problems
• Unsteady gait & frequent falls
• Incontinence
• Personality & mood changes
• Sudden or frequent urge to
urinate
• Wandering at night
Alzheimer’s vs Vascular
Lewy Body Dementias
• Second most common type of progressive dementia
• Lewy bodies = protein deposits
• May cause visual hallucinations, which generally take the form
of objects, people or animals that aren't there
• May have sig fluctuations in alertness and attention
• E.g. daytime drowsiness or periods of staring into space
• Parkinson-like features, e.g rigid muscles, slowed movement
and tremors
• sensitivity to neuroleptics
Lewy body
Parkinson’s Disease
• Usually begins in 60’s
• rigidity
• Characterized by triad of
rigidity, bradykinesia and
tremor at rest
• tremor at rest
• Correlates with degeneration of
dopaminergic nigrostriatal
pathway and dopamine
depletion in the striatum
• Expressionless (mask-like) face
• Slow movement
• Stooped posture
• Shuffling, small-step gait
Parkinson’s Disease
Depigmentation of the substantia nigra in PD (left). Normal
sustantia nigra (right).
Other Types of Dementias
• Huntington’s
• Movement disorder, genetic
• Pick’s
• Frontotemporal dementia:
• disinhibition/lethargy/executive dysfunction
• HIV
• Creutzfeld-Jacobs Disease
Initial and prominent features
• AD: short term memory loss, progressive memory impairment,
disorientation, A3
• Vascular: apathy, gait, memory, visuospatial, processing, memory, stepwise
decline
• LWB: Parkinsonism, episodic fluctuations in arousal and alertness, VH or
illusions, Capgras, autonomic dysfunction, worsens with D2 block
• FTD: 50s & 60s, personality changes, disinhibition, aphasia if left sided,
memory relatively preserved
• NPH: after trauma, infection or hemorrhage, W triad, slowed verbal
responses
• **ALL CAN HAVE DEPRESSIVE OR PSYCHOTIC SYMPTOMS**
Primary Prevention
• Lifestyle
• Pharmacological
Primary Prevention: Lifestyle
• Exercise
• Wine consumption
• 250 - 500ml/day
• Daily mental activities
• Prevention of head injuries
• Smoking cessation
• Diet: omega 3 FA’s, Mediterranean diet
• Education: 15 yrs vs <12 years RR=0.48
• Enviro exposure: pesticides, fertilizer, fumigants
Primary Prevention: Pharmalogical
• NSAID’s
• Vitamin E & C supplements
• HRT
• Ginko biloba – poor evidence, risk of bleeds
• Statins – poor evidence for primary prevention
• All of these are mentioned but the evidence base is poor
Assessment: History
• Course of illness
• Relation to vascular events ie. strokes
• Hx of EtOH abuse, renal failure
• Vascular risk factors
• Other risk factors
Assessment:
Brief Cognitive Tests
• MMSE
• Memory
• Attention
• Construction
• Orientation domains
• Clock drawing exercise
• General executive fxn of frontal lobe
• Visuospatial abilities
Assessment:
Investigations
• CBC (anemia)
• BUN
• TSH (hypothyroid)
• CR
• Lytes (hyponatremia)
• LFTS
• Ca (hypercalcemia)
• CXR
• Mg
• Ur Cx
• Fasting glucose (hyperglycemia)
• Bld Cx
• B12 level (low)
• Folate or RBC folate (low) celiac,
inadequate diet
• Homocysteine - insufficient evidence
Assessment:
Neuroimaging
• Age < 60 years
• Rapid (1–2 mos) unexplained decline in cognition or
function
• Short duration of dementia (< 2 years)
• Recent and significant head trauma
• Unexplained neurologic symptoms (ie. new onset of
severe headache or seizures)
• History of cancer (esp w/ brain mets)
Dementia Management
• Medical Workup and Treatment – VINDICATE
• Rule out and treat depression
• Functional and Safety Assessment
• Psychoeducation (family)
• Medications
• Environmental
• Nursing home, home care supports
Tx: Pharmacological
Cholinesterase
Inhibitors
• Donepezil
• Galantamine
• Rivastigmine – do not use with
delirious patients! 22% mortality
in 2010 Lancet RCT among ICU
patients… this is in the
Rivastigmine arm. Yes, the study
had sufficient power.
NMDA Receptor
Antagonists
• memantine
Cholinesterase Inhibitor
• RCT’s: consistently modest benefit in cognition, ADL &
overall clinical state with all three agents
• Adverse effects
• GI (anorexia, N&V, diarrhea)
• Dizziness
• Sleep disturbances/vivid dreams (Donepezil)
Tx: Combinations
• RCT compared memantine + donepezil to donepezil
alone in patients with mod -severe AD
• Better scores on measures of cognition ADLs, global outcomes &
behavior
• Dropout rate < control
• Memantine often added to cholinesterase inhibitor in
patients with advanced disease