90. Delirium and dementia

Question 1

Hallmark finding in delirium

Answer 1

disturbance in awareness and attention - cannot focus attention or reduced orientation to environment

Question 2

First sign of delirium

Answer 2

reversal sleep wake

Question 3

Name 4 key characteristics of delirium (box 90.1)

Answer 3

• Disturbance in attention and awareness.
• The disturbance develops over a short time period, represents a change
  from baseline attention and awareness, and tends to fluctuate in severity
  during the day.
• There are additional disturbances in cognition, such as memory, disorienta-
  tion, language, visual-spatial ability, or perception.
• The disturbances are not better explained by another preexisting, estab-
  lished, or evolving neurocognitive disorder and do not occur in context of a coma.

Question 4

Name 8 RF for delirium

Answer 4

Advanced age
Male gender
Visual or hearing impairment
Alcohol and drug use
Dementia
Hypertension
Heart failure
Previous delirium
Chronic respiratory disease
Chronic kidney disease
Heart failure
Sedative medications (e.g., benzodiazepines and opioids)
Malnutrition
Depression

Question 5

What are the two most common metabolic disorders that put a patient at risk for delirium

Answer 5

hypoglycemia
hypoxia

Question 6

What is delirium at a cellular level?

Answer 6

widspread alteration of cerebral metabolic activity with secondary deregulation of neurotransmitter synthesis and metabolism

Question 7

What is the underlying process that causes hepatic and uremic encephalopathy, sepsis and etoh withdrawal delirium?

Answer 7

increased glutaminergic activity and neuroinflamm

Question 8

The bCAM uses four key features in screening for delirium:

Answer 8

(1) acute onset and fluctuating course AND (2) inattention
with (3) disorganized thinking OR (4) altered level of consciousness

Question 9

List 2 emergency department tests for delirium

Answer 9

Delirium triage screen
brief confusion assessment method

Question 10

List 4 emergency department tests for dementia

Answer 10

short blessed test
abbreviated mental test
brief alz screen
clock drawing test
MMSE

Question 11

Table 90.3 delirium vs dementia:
onset
attention
LOC

Answer 11

acute vs gradual
impaired vs normal
fluctuates vs normal

Question 12

Table 90.3 delirium vs dementia:
orientation
memory
hallucinations
language

Answer 12

variable vs impaired
often impaired vs impaired
present vs absent usually
slowed, asphasia vs word finding difficulty

Question 13

List 5 diagnostic studies that may help rule in a certain delirium precipitant

Answer 13

vital sings
BG
blood gas
cbc
urine cxr
drug level
trop
CO
ct brain
eeg

Question 14

Acute undifferntiated agitation recommended agents?

Answer 14

haloperidol 0.5-1mg IV or 1-2.5mg IM
droperidol 2.5mg-5IV or 5 IM q30min

Question 15

Parkinson dementia with agitation or acute agitation undifferentiated agent for agitatio

Answer 15

quetiapine 12.5-25mg po 1-2x daily
olanz 2.5-5mg IM or IV q2-4h

Question 16

Agitation from acute intoxication or withdrawal syndromes; acute undifferentiated agitation

Answer 16

loraz0.5–1 mg IM or IV every 4–6 hours as needed
midaz 2.5–5 mg IV or IM every 15 minutes as needed

Question 17

Dementia defn

Answer 17

gradual progressive cognitive decline in complex atten- tion, executive function, learning and memory, language, perceptual motor function or social cognition that interferes with daily function and independence.

Question 18

MC types of dementia

Answer 18

predominant dementia is Alzheimer dementia repre- senting 60% to 80% of all cases; vascular dementia represents 20% of all cases, and dementia from multiple etiologies represents 20%

Question 19

List 4 primary dementias

Answer 19

Alzheimer dis- ease, dementia with Lewy bodies, subcortical dementias involving the basal ganglia and thalamus (e.g., progressive supranuclear palsy, Huntington chorea, Parkinson disease), and dementia of the frontal lobe type, which includes Pick disease. Dementia with Lewy bodies, clinically manifested by persistent, well-formed visual hallucina- tions and prominent extrapyramidal movements

Question 20

List 4 causes of intracranial process that can cause dementia

Answer 20

Space occupying lesions (tumor, subdural hematoma)
Hydrocephalus
CNS infections (i.e., HIV-1, neurosyphilis, chronic meningitis, encephalitis sec-
ondary to measles, John Cunningham (JC) virus, rubella, Candida albicans, Creutzfeldt-Jakob disease (CJD), and variant CJD subacute spongiform viral encephalopathies, or slow virus infections)
Repetitive head trauma

Question 21

List 4 endocrinopathies that can cause dementia

Answer 21

Addison and Cushing diseases Thyroid and parathyroid disease

Question 22

List 4 nutritional deficiencies that can manifest as dementia

Answer 22

thiamine
niacin
folate
vit b12

Question 23

list 3 toxic exposures that can cause dementia

Answer 23

heavy metal
co
carbon disulfide

Question 24

list 4 drugs that have dementia like effecs

Answer 24

Psychotropics Antihypertensives Anticonvulsants Anticholinergics

Question 25

what mental health disorder can manifest as dementia

Answer 25

pseudodementia

Question 26

Box 90.3 diagnostic criteria for dementia

Answer 26

A. Cognitive decline from a previous level of performance in one or more cognitive domains: Complex attention, executive function, learning and memory, language, perceptual motor function, or social cognition. B. The disorder has an insidious onset and gradual progression. C. The deficits do not occur exclusively during the course of a delirium. D. The cognitive deficits are not better explained by another mental disorder, such as major depression or schizophrenia.

Question 27

Predominant brain change in alzheimers

Answer 27

cortical atrophy most prominent in the tempo- ral and hippocampal regions caused by progressive synaptic and neu- ronal loss in the cerebral gray matter. followed by whit matter loss

Question 28

Histologic features of Alzheimer disease

Answer 28

extracellular deposition of β-amyloid protein and intracellular neuro- fibrillary tangles contributing to neuron loss.

Question 29

RF for Alz/vascular dementia

Answer 29

DLD High BP dementia apolipopro E

Question 30

Multi infarct dementia involves which parts of brain?

Answer 30

cerebral hemisphere basal ganglia

Question 31

How does Creutzfeldt-Jakob disease occur?

Answer 31

prion is a proteinaceous infectious particle with the apparent ability to start a chain reaction that changes the shape of benign pro- tein molecules into abnormal, slowly destructive forms. These diseases cause a fine vacuolation of the nervous tissue and hence are referred to as subacute spongiform viral encephalopathies. With these diseases, months to years pass between infection and the appearance of clinical illness.

Question 32

early signs of dementia

Answer 32

anxiety, depression, insomnia, frustration, and somatic complaints that often are more prominent than the memory loss

Question 33

One of several features that distinguish cortical from subcor- tical dementias is...

Answer 33

prominent movement disorder

Question 34

CJD - typical feature?

Answer 34

myoclonus

Question 35

NPHydrocephalus classic triad

Answer 35

progressive dementia ataxia urinary incontinence

Question 36

Box 90.4 List elements in the mental status exam in evaluation of dementia that are routinely observed

Answer 36

Appearance, behavior, and attitude Mood and affect

Question 37

Box 90.4 List elements in the mental status exam in evaluation of dementia that require inquiry

Answer 37

Sensorium and intelligence: Cognitive impairment Disorders of thought: Suicidal and homicidal ideation Insight and judgment: Knowledge about illness Disorder of perception: Hallucinations and delusions

Question 38

Constructional apraxia defn

Answer 38

sessed by having the patient perform tasks, such as drawing interlocking geometric figures or clock faces and connecting dots.

Question 39

dysnomia vs dyspgraphia defn sn for what?

Answer 39

**** Dysnomia (inability to name objects correctly) and dysgraphia (impaired writing ability) are two of the most sensitive indicators of delirium superimposed on dementia.

Question 40

MMSE sn and sp

Answer 40

sensitivity of 87% and a specificity of 82% for detection of organic brain syndrome.

Question 41

Name 3 drugs for Alzheimer's

Answer 41

cholinesterase inhibitors donepezil (Aricept), rivastigmine (Exelon), and galantamine (Raza- dyne)

Question 42

SE of drugs for Alzheimer's

Answer 42

nausea vomiting diarrhea

Question 43

How does memantine work?

Answer 43

reg- ulate the excitatory effects of glutamate by antagonizing the N-methyl- d-aspartate receptor

Question 44

1. Which of the following characteristics helps distinguish dementia from delirium? a. Acuteonset b. Memory impairment c. Disorientation d. Delusions

Answer 44

a

Question 45

2. A 78-year-old woman presents with 3 days of decreasing ability to concentrate, memory and cognition breakdown, sleep cycle disrup- tion, and fluctuating levels of agitation. Her current medications include levofloxacin (Levaquin) 500 mg/day for a bladder infection, tramadol PRN for knee arthritis, and hydrochlorothiazide 25 mg/ day for essential hypertension. Her examination is normal except for a baseline tachycardia, moderate agitation and restlessness, and orientation to person only. Laboratory analysis shows glucose 198 mg/dL, sodium 131 mEq/L, potassium 3.8 mEq/L, creatinine 1.4 mg/dL, white blood cell (WBC) count 11,300 cells/mm3, hemoglo- bin 12 g/dL, bicarbonate 25 mEq/L, and a normal urinalysis. What is the most likely etiology for her delirium? a. Earlysepsis b. Hyperglycemia c. Hyponatremia d. Medication effect

Answer 45

d

Question 46

An 82-year-old man presents with acute delirium. On examination, he is alert and mildly agitated. He is oriented to person and place but not time. He is easily distracted and exhibits a mild bilateral upper extremity resting tremor without asterixis. His neurologic examination is nonfocal. His short-term memory is impaired. What is the central component most key to the diagnosis of delirium in this case? a. Agitation b. Disorientation c. Inattention d. Memory dysfunction

Answer 46

c

Question 47

4. Which of the following associations is correct? a. Droperidol: QT prolongation b. Haloperidol: Dysphoria c. Lorazepam:Excessivehalf-life d. Meperidine: Cholinergic effects

Answer 47

a

Question 48

. A63-year-oldmanpresentswithacute-onsetdelirium.Heisaknown alcoholic, and the family reports a cessation of alcohol intake 36 hours before presentation. He has no other known medical problems. Exam- ination is remarkable for an acutely delirious patient who has active visual and auditory hallucinations and a tremor. Neurologic examina- tion is otherwise negative. Finger-stick glucose is normal. Thiamine 100 mg intravenously fails to improve his symptoms. Which of the following is the intervention most likely to prevent further worsening? a. Dextrose b. Haloperidol c. Lorazepam d. Magnesium

Answer 48

c