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Organic brain disorders
Wiktor Drózdz
Organic brain disorders (F0x)
• Cognitive impairment disorders
– Mild cognitive impairment (MCI): F06.8
– Dementia (different types): F00, F01, F02
•
•
•
•
Organic psychotic disorders (F06.2)
Organic mood disorders (F06.3)
Organic anxiety disorders (F06.4)
Organic behavioral disorders (F07)
What are Normal Age-related Changes?
Rate of information processing

Acquisition performance (learning)

Early retrieval of new information

Delayed recall (forgetting)

Distractibility

Self reported memory loss

Vulnerability to fatigue, illness, medication
side effects
• No functional decline
•
•
•
•
•
•
•
Model of Continuum of Cognition with Aging
Normal
Mild cognitive impairment
Probable AD
Function
Dementia
Definite AD
Dementia
Age
Mild Cognitive Impairment
•
•
•
•
•
•
Memory complaint
Objective memory impairment
Normal general cognitive function
Intact activities of daily living
10-20% per year progress to dementia
At 10 years 20% NOT demented
Older patients with memory complaints
attending a neurologist (n=130)
Kłodowska-Duda et al. Neuro-Care Katowice
Clinically significant memory impairment
(CIND) & dementia prevalence over age 65
65 to 74 yrs
CIND
(n=861)
11%%
Dementia
(n=1132)
2.4%
75 to 84 yrs
24%%
11%%
> 85 yrs
30%%
35%%
Overall
17%
8%
Graham J et al: Lancet 349:1793-1796, 1997
Definition of Dementia
The diagnostic criteria include the presence of :
• memory impairment plus at least one other of following
features: aphasia, apraxia, agnosia or executive
dysfunction
• associated with a decline from previous cognitive
functioning and
• functional impairment (this differentiates dementia from
MCI), usually affecting IADLs (Instrumental Activities of
Daily Living
• Its important that other cause of worsening cognition are
considered before making a diagnosis of dementia.
Depression and delirium are important differentials to
consider.
Percentage changes in selected causes of death (all ages)
between 2000 and 2010.
Created from data from the National Center for Health Statistics
Types of dementia
1.
2.
3.
4.
5.
6.
7.
Alzheimer Disease
Mixed AD/Vascular Dementia
Lewy Body Dementia
Frontotemporal Dementia
Vascular Dementia
Other
“Reversible”
40-50%
15-20%
10-20%
5-10%
5-10%
5%
<5%
Proportion of people with AD in the United States
by age (Hebert et al. 2013)
The projected number of people aged 65 years or older
(total and by age group) in the United States population
with AD, 2010 to 2050.
(Hebert et al. 2013, Alzheimer’s Association Report 2014)
Why Try to Make an Early Diagnosis
of Dementia?
• Helps family understand and make sense of the changes
they have seen
• Early link of patient and family with informal and formal
supports
• To prepare patient and family for future course of the
illness
• With mild dementia possibility of involving the patient in
advanced care planning e.g. living wills etc
• Opportunity to modify risk factors e.g.. DM, BP, etc
• Impact of non-pharmacological therapies probably
greater e.g. cognitive and physical exercise
• Cholinesterase Inhibitors can delay symptomatic
progression of dementia
What arouses our suspicion for dementia?
• Family reports concerns re memory or function
or behavior
• Change in personality, appearance or behavior
• Missed appointments
• New problems with medication compliance
• Forget to bring in their medications and can’t tell
you what they’re taking
• Presence of risk factors (family history, vascular
risk factors, previous head injury or stroke)
Alzheimer’s Society 10 Warning Signs
for Caregivers
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Memory loss that affects day-to-day function
Difficulty performing familiar tasks
Problems with language
Disorientation of time and place
Poor or decreased judgment
Problems with abstract thinking
Misplacing things
Changes in mood and behaviour
Changes in personality
Loss of initiative
Symptoms of Dementia
• Problems with short term memory
o
o
o
o
Appointments
Conversations
Events
Repeating stories
• Difficulty remembering
names, faces
o
Forgetting acquaintances
and friends
Things which have been more problematic…
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Trouble making sense of language
Trouble finding the right word
Difficulty naming objects
Understanding complicated instructions
Trouble doing familiar things
Driving, banking
Cooking, cleaning, laundry
Dressing, bathing
Confusion in unfamiliar places
Getting lost
Personality changes
Easy to anger, emotional
Suspicious
Seeing or hearing things that aren’t there
Risk factors for developing AD
Definite Risk
PutativeRecent
PutativeOlder
Protective
age
women
depression
NSAIDS
Apo E4
Low
education
Head trauma
Estrogen?
Family
history
Vascular
factors
alcohol
Smoking?
MCI
Hypertension
Aluminum?
Diet?
Smoking?
Physical
exercise?
Vascular Risk Factors for Dementia
•
•
•
•
•
•
•
•
Diabetes Mellitus
Hyperlipidemia
Hypertension
Stroke/TIA
Atherosclerosis
Smoking
Obesity
Atrial fibrillation
Seshadri et al. 2002
Other risk factors for dementia
• 1st Onset Depression over age 65 (30%)
• Retirement Home residents (30%)
• Lower education level
AD Pathology
Amyloid plaques (A)
Progression of ADL loss in
Alzheimer Dementia
30
Mild AD
25
Impaired
instrumental ADLs
20
MMSE
Moderate AD
Impaired
in 1 or
more basic ADLs
15
10
Severe AD
5
Requires
assistance for
most basic ADLsPalliative AD
1
2
3
4
5
Years
6
7
8

9
Social
interaction
Dependent in
all ADLs
Progression of Alzheimer Dementia
Proportion of caregivers of people with AD and other dementias
versus caregivers of other older people who provide help with
specific activities of daily living, United States, 2009
Proportion of AD and dementia caregivers who report high
or very high emotional and physical stress due to
caregiving (Alzheimer's Association Report 2014)
Impact on Caregivers
• Mismatch between capacity
and expectations
• Mismatch in present and
past roles of individual
• Failure of individual affected
to recognize or appreciate
issues
• Behaviors and actions that
challenge historical
relationships
• Guilt of caregiver regarding
need for help
Impact on institutional caregivers
• Comorbidities
• BPSD
• Insufficient support
from families
• Formal Caregivers
report behaviors such
as aggression, calling
out and disruptive
behavior, typically less
well tolerated than at
home
Hospital stays per 1000 beneficiaries aged 65 years or
older with specified coexisting medical conditions,
with and without AD and other dementias.
(Alzheimer's Association Report 2014)
Physicians role in Dementia
• careful assessment, identification of all
contributory factors and probable
diagnosis
Diagnosis of Dementia
• No one test can diagnose dementia
• Memory tests or brain scans alone are not
enough
• Diagnosis is made after combining the
medical assessment and memory tests
Diagnosis of AD
Progressive decline in cognition and/or
function:
History from patient and reliable informant
+
Mental and functional status assessments
+
Physical examination
+
Laboratory tests
•
•
•
•
•
•
Onset & duration
Evolution of symptoms
Precipitating factors
Family history
Medication history
Rule out Depression/Delirium
Cognitive and Functional Activities
Assessment
Rule out:
• Adverse drug effects
• Neurological disease
• Metabolic or systemic illness
•
•
CBC, TSH, electrolytes,
calcium, glucose
CT or MRI in specific cases
Alzheimer’s disease
1.
2.
3.
4.
Disclose diagnosis to patient and family, and
inform about the disease
If mild-to-moderate: initiate therapy as per
treatment guidelines
Treat other symptoms
Educate and support both patients and
caregivers; refer families to support
organizations
Other dementia
Assess further or refer
Adapted from Patterson C et al. Can J Neurol Sci, 2001.
Examples of Office
Cognitive Assessment Tools
Possible Dementia
– Dementia Quick Screen
– Folstein MMSE
– Montreal Cognitive Assessment (MOCA)
– Clock Drawing Test
– Trail Test
36
Dementia Quick Test
• 3 item recall (2/3 is normal)
• 4-legged animals in 1 minute (<15 abnormal )
• Clock drawing (hands at 10 past 11)
• If one or more of the screening tests are positive,
the person and an “informant” should be asked if
there have been any memory or functional
changes over the last 6 – 12 months, and formal
cognitive tests should be done (MMSE, MOCA,
etc.).
Interpretation: 3-word recall
• The probability of cognitive impairment is significantly
reduced if all 3 words are recalled correctly
• If less than 2 words are recalled correctly
the likelihood ratio for cognitive impairment is
increased
# Words
recalled
Likelihood
ratio
3
0.06
2
0.5
<2
3.1
Interpretation: clock drawing
• Many scoring schemes have been developed for the clock
•
•
drawing test (which tests memory, visuospatial and
executive functions)
Most clinicians use a “gestalt” impression of normal, mildly
abnormal and abnormal
The aspects usually assessed include a reasonable joined
circle, number placement and hand placement
Normal
Mildly abnormal
Correct hand placement
Minor spacing problems
Abnormal
Incorrect hand placement
Incorrect number placement
Cognition assessment: MMSE
The annotated Mini-Mental State Examination
(MMSE) is a brief instrument commonly used to
assess patients with dementia
The MMSE is scored out of 30 points; a total score
of 23 or less suggests dementia (although the cutoff varies with age and education)
Limitations include poor sensitivity in detecting MCI,
and if conducted late during the course of many
dementias, the test has a “floor effect”
Guidelines for managing Alzheimer’s disease: Part I. Jeffrey L. Cummings, MD et al. American Family Physician, June 15, 2002.
40
Functional Assessment and Dementia
• In assessing a patient with
dementia, it is critical to determine
the impact on functional abilities.
• Typically the first functional areas
affected are the instrumental
ADLs (IADLs) –mnemonic:
SHAFT
S
H
A
F
T
Shopping
Housework
Accounting
Food preparation
Transportation
• Other areas of function affected
early include driving, medication
management, using the telephone
and doing laundry.
Lab tests
All
Most
Some
HB and CBC
Serum B12
MRI
Electrolytes
Folate
MRI with PBI
Glucose
Calcium
EEG
TSH
CT Scan
Lumbar
Puncture
LFTs
HIV
New Imaging Technology for AD
67 yo NL
79 yo AD
PET scan
Amyloid
detection
Nordberg
Lancet Neurology
2004
Atrophy in Alzheimer’s disease
Atrophy of the brain in AD: Medial temporal lobes are
affected first and most severely
Hippocampal volume in
Alzheimer’s
disease
AD
Normal
tMTL width = 2.6 mm
tMTLwidth = 14.6 mm
Dark lines cross the thinnest width of the hippocampus and arrowheads indicate
hippocampal boundaries.
Red Flags






Visual hallucinations – (detailed / recurrent).
Pronounced fluctuation in cognition over hrs/days.
Parkinsonism (especially rigidity) / bradykinesia.
Executive function worse than memory.
Neuroleptic sensitivity.
Unexplained falls / loss of consciousness.
THINK OF:
Lewy Body Dementia
Clinical features
DLB
AD
Type of memory impairment
Semantic Memory
Episodic memory
Isolated memory impairment
93.8%
31.3%
Fluctuation of cognitive
function
50-75% as feature of
presentation
When delirious
Verbal Memory
Usually intact or mildly
affected
Commonly affected
Executive function
Poor early in the course
Less severe in early phase
Attention, visuospatial
function,
& constructional abilities
More impairment early in
course
Less impairment
Visual hallucinations
Common since early phase
Less prominent in early course
Psychiatric symptoms
Common and early in the
course
Less likely
Neuroleptics response
Extrapyramidal side effect;
may cause mortality
Behavioral response
Parkinsonism
Common early
Less common and late feature
Autonomic involvement
Common
Less common
Red Flags
 Cognitive decline within 3 months of CVA / TIA.
 Focal neurological symptoms.
 Abrupt onset / stepwise decline.
 Previous CVA or TIA.
 Executive function worse than memory.
THINK OF:
Vascular dementia
mixed AD / vascular
Red Flags
 Behavioral changes: disinhibition / apathy.
 Impulsivity / poor judgment.
 Self neglect / socially inappropriate.
 Executive function worse than memory.
 Language problems.
THINK OF:
Frontotemporal
Dementia
Clinical features
FTD
AD
Age at onset
Rarely > 75 years
Increases markedly with age
Early behavioral problems
Common
Unusual
Socially inappropriate behaviors
Common early in the course
Usually in severe case
Memory impairment
Less prominent in early course
Early prominent feature
Language problems
May have isolated language
problems without memory
impairment
Usually associated with
memory impairment
Visuospatial defect
Rare in mild to moderately impaired
case
Common
Motor signs
More common (in FTD with motor
neuron disease)
Less common
Mood
Marked irritability, anhedonia,
withdrawal, euphoria, lack of guilty,
apathy or suicidal ideation
Sadness, tears, anhedonia,
apathy, guilt
Psychotic features
Rare persecutory delusion, usually
jealous somatic, religious and
bizarre behaviors
May have delusion of
misidentification or
persecutory type in middle or
later stage
Appetite, dietary change
Increased appetite, carbohydrate
craving 80% weight gain
Less common: anorexia and
weight loss
Red Flags
 Abnormal gait
 Incontinence early in course of dementia
 Rapidly progressing dementia
THINK OF:
Normal Pressure
Hydrocephalus
(NPH)
SUMMARY: Dementia Types
AD: short term memory, word finding, way finding.
LBD: fluctuations, hallucinations, Parkinsonism.
FTD: behaviour, social tactlessness, language.
VaD: vascular history, focal findings, +ve imaging.
Mixed AD/VaD: clinical, radiologic +ve imaging.
Other types of dementia
•Parkinson’s Disease
•Huntington’s Disease
•Creutzfeldt Jakob Disease
•Progressive Supranuclear Palsy
•Korsakoff’s Syndrome
•Infection-Related Dementia (HIV, Syphilis)
Physicians role in Dementia
• careful assessment, identification of all contributory
factors and probable diagnosis
• communicating the findings and diagnosis and
discussing probable natural history and treatment
options
Disclosure of Diagnosis
1. The process of diagnostic disclosure for
persons with cognitive impairment or dementia
must begin as soon as the possibility of
cognitive impairment is suspected.
During the initial investigations of complaints or
suspicions of cognitive loss, the patient’s
understanding and attitudes about cognitive
loss and dementia, as well as that of their
family members/caregivers should be
established.
Disclosure of Diagnosis
1. Both the diagnosis of dementia and the
disclosure of the diagnosis must be considered
processes that provide opportunities for
education and discussion.
2. The potential for adverse psychological
consequences must be assessed and
addressed through education of the patient
and family/caregivers.
Disclosure of Diagnosis
1. Once a diagnosis is established, this
must be disclosed to the patient and their
family/caregivers in a manner that is
consistent with the expressed wishes of
the patient.
1. Follow-up plans must be made and
discussed at the time of diagnostic
disclosure.
Physicians role in Dementia
• careful assessment, identification of all
contributory factors and probable diagnosis
• communicating the findings and diagnosis and
discussing probable natural history and treatment
options
• responding to common questions and
concerns
Common Questions and Concerns
• What "type and severity of dementia" is present?
• What is the prognosis and timeline?
• What are typical symptoms of disease we can expect as
it progresses?
• Are other member so family going to develop similar
problems?
• What prescription medications or over-the-counter
(including herbal or experimental) remedies may be
useful?
• What restrictions should be placed on the patient's
current activities or life style?
– Finances
– Power of Attorney
– Driving
Physicians role in Dementia
• careful assessment, identification of all contributory
factors and probable diagnosis
• communicating the findings and diagnosis and discussing
probable natural history and treatment options
• responding to common questions and concerns
• optimizing of cognitive, medical and functional status
and reduction of ongoing risk factors,
Optimizing of cognitive, medical and functional
status and reduction of ongoing risk factors
• Common co-morbid medical conditions to review include:
cardiovascular disease, pulmonary disease, hypertension, DM, renal
insufficiency, arthritis, and diminution of vision/hearing.
• Review and rationalize medication usage
• There is good evidence for following in terms reducing ongoing risk of
stroke and possibly dementia:
– treat systolic hypertension (>160mm) in older individuals.
– ASA and statin medications following myocardial infarction; antithrombotic
treatment for non-valvular atrial fibrillation; and correction of carotid artery
stenosis >60%
• Insufficient evidence that treatment of type 2 diabetes, hyperlipidemia
and hyperhomocysteinemia reduces the risk of dementia.
• There is good evidence to avoid the use of estrogens for purpose of
reducing the risk of dementia.
• High dose vitamin E (400 units/day) should not be recommended
Physicians role in Dementia
• careful assessment, identification of all contributory
factors and probable diagnosis
• communicating the findings and diagnosis and discussing
probable natural history and treatment options
• responding to common questions and concerns
• optimizing of cognitive, medical and functional status and
reduction of ongoing risk factors,
• an anticipatory care plan sensitive to ethico-legal
issues that includes monitoring, mobilization of
patient and caregiver supports and adjustment of
strategies
Care of the patient with Dementia (I)
• Inform and teach the patient, family and
caregivers about the nature and
progression of the disease.
• Refer to Alzheimer’s society
• Review Driving
• Advice on the role of attorney
• Genetic testing?
• Discuss future plans and availability of
community supports
Caregiver Supports
The clinician should:
• enquire about caregiver information and support needs
• provide education to patients and families about dementia
• assist in recruiting other family members and formal
community services to share the caregiving role.
• It is important that the clinician enquire about disruptive
behaviors and the effect they are having on the caregiver.
• If available suggest referral of patients to services such as
– Community Care Access Center,
– Community Support Services such as meals on wheels, friendly visitor
programs, volunteer drivers,
– Respite and Day Care Programs
Care of the patient with Dementia (II)
• Maintain high level of activity (exercise programs,
daily activities).
• Nutrition. Check for weight loss and nutritional
indices (B12, albumin)
• Encourage personal and social functions as
much as possible
• Actively treat geriovascular risk factors: atrial
fibrillation, hypertension, hyperlipidemia and
diabetes
• Consider AChEI therapy
• Establish patient/caregiver expectations: therapy,
goals, and target symptoms for monitoring (can
also keep diary).
Physicians role in Dementia
• careful assessment, identification of all contributory factors and
probable diagnosis
• communicating the findings and diagnosis and discussing probable
natural history and treatment options
• responding to common questions and concerns
• optimizing of cognitive, medical and functional status and reduction of
ongoing risk factors,
• an anticipatory care plan sensitive to ethico-legal issues that includes
monitoring, mobilization of patient and caregiver supports and
adjustment of strategies
• Use of ACEI’s and Memantine
AChEIs: meta-analysis
(Lanctôt et al CMAJ 2003)
Benefits Seen in AD RCTs (mild-moderate)
• Global and Cognitive (ADAS-Cog 3-5 points over 24 weeks)
– clinical impression : 18-48% in RCTs
– Meta-analysis: Need to Tx for stabilization 7, min improve 12,
marked improve 42
• Function
– instrumental and personal activities of daily living
• Behaviour
– prevention of problems in mild dementia, treatment effect in
moderate to severe dementia.
• Decreased psychotropic use in long-term care
• Reduced caregiver time - helping directly with ADLs (1
hr/day)
• Reduced risk for nursing home placement (Relative Risk
Reduction = 37%, p = 0.004)
Benefits of AChEIs ?
• AChEIs are “symptomatic” drugs (control symptoms but
do not affect the progression of the disease).
• The risk of no treatment is 100% progression.
• Side effects are usually mild & self-limited (tell patients to
consult again if not resolved within 1/52).
– GI: nausea, vomiting, diarrhea, bloating, anorexia.
– Muscle cramps, fatigue, dizziness, incontinence.
– Sleep disturbance: insomnia, nightmares.
• Cholinergic effects may affect asthma, ulcers,
bradycardia / heart block (do ECG if cardiovascular
history / risk factors).
• Current evidence suggests the cholinesterase inhibitors
have similar efficacy at maximum recommended doses
Approved AchEIs
T1/2
Drug
Interaction Elimination Metabolism
Potential
Name
Selectivity
Donepezil
(Aricept)
AChEI
70-80
HR
Low
Liver
CYP2D6
Rivastigmine
(Exelon)
AChEI &
BuChEI
2 HR
Very Low
Kidney
No Hepatic
Galantamine
(Reminyl)
AChEI &
Nicotonic 7-10 HR
Modulator
Low
Liver and
Kidney
CYP2D6
CY3A4
Treatment recommendations
Memantine is an option for patients with moderate stages of
AD. Its use in mild stages of AD is not recommended.
Combination therapy of a cholinesterase inhibitor and
memantine is rational (as the medications have different
mechanisms of action), appears to be safe and may lead
to additional benefits for patients with moderate to severe
AD. This would be an option for patients with AD of a
moderate severity.
While Ginkgo biloba is a safe agent, its use can not be
recommended for the treatment of dementia. Further
methodologically sound trials are required.
Memantine in Advanced AD
Memantine-treated patients demonstrated
benefits in:
– Global function, as shown by a clinician’s assessment of change
reflected by slower decline in CIBIC-plus scores versus placebo
– Activities of daily living, as shown by a slower decline on the
ADCS-ADLsev scale versus placebo
– Cognition, as shown by a slower decline in scores on the SIB scale
versus placebo
Memantine was safe and well tolerated in this
patient cohort
Data suggests that memantine may be useful
in patients with advanced AD
Reisberg et al. N Engl J Med, 2003
Memantine/Donepezil in Advanced AD
Memantine/donepezil-treated patients demonstrated
benefits in:
– Cognition, as shown by improvement in scores on the SIB scale versus
placebo/donepezil
– Activities of daily living, as shown by a slower decline on the ADCS-ADL
scale versus placebo/donepezil
– Global function, as shown by a clinician’s assessment of change reflected
by a slower decline in CIBIC-plus scores versus placebo/donepezil
– Behaviour, as shown by improvements on the NPI total score versus
placebo/donepezil
The memantine/donepezil combination was safe and well
tolerated in this patient cohort. Data suggest that a
memantine/CHEI combination may be useful in patients
with advanced AD
Tariot et al. JAMA, 2004
Non-pharmacological treatments in dementia
1. There is good evidence to indicate that
individualized exercise programs have an
impact on functional performance in persons
with mild to moderate dementia.
2. There is insufficient research evidence to come
to any firm conclusions about the effectiveness
of
i. cognitive training/cognitive rehabilitation
ii. environmental interventions
iii. other non-pharmacological therapeutic interventions
Physicians role in Dementia
• careful assessment, identification of all contributory
factors and probable diagnosis
• communicating the findings and diagnosis and discussing
probable natural history and treatment options
• responding to common questions and concerns
• optimizing of cognitive, medical and functional status and
reduction of ongoing risk factors,
• an anticipatory care plan sensitive to ethico-legal
issues that includes monitoring, mobilization of patient
and caregiver supports and adjustment of strategies
• Use of ACEI’s
• collaboration with other health providers and
community agencies
• identification of psychiatric co-morbidities
Physicians role in Dementia
• monitoring for and anticipating
common issues and concerns
– driving,
– delirium,
– disruptive behaviors,
– sleep disruption
– wandering
– opposite behaviors
Driving and Dementia
• Clinicians should counsel persons with a progressive
dementia (and their families) that giving up driving will be
an inevitable consequence of their disease.
• No single brief cognitive test (e.g., MMSE) or combination
of brief cognitive tests has sufficient sensitivity or specificity
to be used as a sole determinant of driving ability.
• Abnormalities on cognitive tests such as the MMSE, clock
drawing, and Trails B should result in further in-depth
testing of driving ability.
• Driving is contraindicated in persons who, for cognitive
reasons, have an inability to independently perform multiple
IADLs (e.g. medication management, banking, shopping,
telephone use) or any of the basic ADLs (e.g. toileting,
dressing).
• For persons deemed safe to drive, reassessment of their
ability to drive should take place every 6 to 12 months or
sooner if indicated.
Common Issues: Disruptive behaviours
• Disruptive behaviors or behavioral and psychological symptom of
dementia (BPSD) are a common feature in the management of
dementia.
• The management of BPSD should begin with appropriate assessments,
diagnosis, and identification of target symptoms and consideration of
safety of the patient, their caregiver and others in their environment.
• Non-pharmacological treatments should be initiated first.
• Pharmacological interventions for BPSD should be initiated at the
lowest doses, titrated slowly and monitored for effectiveness and safety.
– Risperidone and olanzapine can be used for severe agitation, aggression
and psychosis: the administration should be as short as possible (chronic
neuroleptic tretament in older age is associated with elevated risk of
mortality)
– Benzodiazepines should be used only for short periods in situations where
alcohol or benzodiazepine withdrawal is present.
– SSRIs can be used for the treatment of severe depression.
Common Issues: delirium
• Delirium is a disturbance of consciousness with
reduced ability to focus, sustain, or shift attention.
It is a change in cognition that occurs over a short
period of time and tends to fluctuate over the
course of the day
• disorientation, memory deficits and hallucinations
• motor signs includes agitation, myoclonus,
asterixis and “picking at non-existent objects”
• multiple predisposing and precipitating factors:
dehydratation, constipation, fever, brain
circulation insufficiency
• may be life-threatening
Delirium is common
• Delirium has been found in 40% of
patients admitted to intensive care units.
• Prevalence of postoperative delirium
following general surgery is 5-10% and as
high as 42% following orthopedic surgery.
• As many as 80% of patients develop
delirium near death.
Confusion Assessment Method
Acute Change in mental status
AND
Inattention/fluctuation
PLUS
Disorganized thinking
OR
Altered level of consciousness


Sensitivity 94 - 100%
Specificity 90 - 95%
Ann Intern Med 1990; 113:941
Arch Intern Med. 1995; 155:301
Depression in older age
•
•
•
•
•
•
•
Cognitive impairment, pseudo dementia
Importuning
Irritability
Non-endorsement of depressed mood
Physical symptoms
Lack of engagement in recovery from
serious illness
May co-exist with dementia
Depression and suicide risk
• Impending
– Somatic complaints
– Agitated
– Sleeplessness
– Frequency of expression
– Plan/intent
– Significant loss of support
– Plans for after death
– Protective factor lost
Effective treatments of organic
depressive/anxiety disorders
• SSRI,
• venlafaxine,
• moclobemide,
• bupropion,
• mirtazapine
low anti-cholinergic properties and usually lowerer risk of
drug-drug interactions but
side effects to watch for in the elderly:
- early in treatment: headaches; nausea and GI upset;
QTc prolongation!
- chronic administration: GI bleeding, bone fractures
Medication-resistant depression in old age:
consider ECT