Dementia and Delirium Flashcards
(78 cards)
1
Q
Why do we care about dementia?
- “_______” population
- By 2030, there may be 70 million elderly in the US (currently around 35 million)
- Current prevalence rates of dementia
- 6-8% if older than ___
- 30% if older than ___
A
- “Graying” population
- By 2030, there may be 70 million elderly in the US (currently around 35 million)
- Current prevalence rates of dementia
- 6-8% if older than 65
- 30% if older than 80
2
Q
Screening for Cognitive Impairment: Policy Update
- _________ benefit: Annual Wellness Visit
- Cognitive assessment for ______ detection
- Personalized health ____ assessment (HRA) and _____ plan
- Incentives
- For patients: ___ deductible or co-pay
- For physicians: _________ equivalent to Level 4 E/M
A
- Medicare benefit: Annual Wellness Visit
- Cognitive assessment for early detection
- Personalized health risk assessment (HRA) and prevention plan
- Incentives
- For patients: no deductible or co-pay
- For physicians: reimbursement equivalent to Level 4 E/M
3
Q
What is Dementia?
- Impairment in ______ function affecting more than one ______ domains
- Interferes with s_____ or o______ function
- De____ from a previous level
- Not explained by de_____ or major ______ disease
A
- Impairment in intellectual function affecting more than one cognitive domains
- Interferes with social or occupational function
- Decline from a previous level
- Not explained by delirium or major psychiatric disease
4
Q
Cognitive Domains
- (1) (frontal, hemispheric white matter)
- (1) (medial temporal lobes/hippocampus)
- (1) (left hemisphere, usually)
- (1) (occipital, parietal)
A
- Executive function (frontal, hemispheric white matter)
- Memory (medial temporal lobes/hippocampus)
- Language (left hemisphere, usually)
- Visuospatial (occipital, parietal)
5
Q
Aphasia
- Able to in____ and m______ a conversation
- Impaired com________
- Intact (2) however the speech is _____ with _____phasias, cir______, t_______and often using non______ phrases (“the thing”)
- Later language can be severely impaired with m_____, e______
A
- Able to initiate and maintain a conversation
- Impaired comprehension
- Intact grammar and syntax however the speech is vague with paraphasias, circumlocutions, tangential and often using nonspecific phrases (“the thing”)
- Later language can be severely impaired with mutism, echolalia
6
Q
Apraxia
=
Contributes to loss of (1)
A
Inability to carry out motor activities despite intact motor function
Contributes to loss of ADLs
7
Q
DSM 5 Criteria
(5)
A
- Dementia of the Alzheimer’s Type (DAT)
- Dementia of the Vascular Type
- Dementia with Lewy Bodies
- Frontotemporal Dementia
- Delirium
Collaboration, collaboration, collaboration, + consulting* (geriatric specialist)
8
Q
Dementia Subtypes
- Early onset =
- Represents what % of cases?
- Strong _____ link
- Tends to progress more ______
- Late onset =
- Represents _____ of cases
A
- Early onset: before the age of 60
- Less than 5% of all cases of AD
- Strong genetic link
- Tends to progress more rapidly
- Late onset: after age 60
- Represents the majority of cases
9
Q
Alzheimer Disease
=
- ______ neurodegenerative and dementing disease
- Prevalence ____ every 5 years after 65, ~___% of those older than ___
- Confirmation of Diagnosis =
A
Progressive neurological condition characterized by the buildup of proteins in the brain called “plaques” and “tangles”
- Commonest neurodegenerative and dementing disease
- Prevalence doubles every 5 years after 65; ~50% of those older than 85
- Confirmation of Diagnosis is dependent on brain biopsy after death*
10
Q
Alzheimer’s Risk Factors
- A___
- (1) positivity
- ______ History in (1) (especially if ______ onset)
- (1) (diabetes, heart disease, etc)
- Low (3)
- ______ sex
A
- Age
- ApoE-e4 positivity
- Family History in first degree relative (especially if younger onset)
- Vascular risk (diabetes, heart disease, etc)
- Low education and physical/social activity
- Female sex
11
Q
Alzheimers Clinical Features
- First noticeable symptom?
- Earliest cognitive symptoms (2)
- Pattern of decline?
- Other domains develop when?
A
Increasing memory loss over time is often the first noticeable symptom
Earliest cognitive symptoms are usually poor short term memory; loss of orientation
Smooth, usually slow decline without dramatic short-term fluctuations
Other domains involved with time
12
Q
Alzheimers Common Signs
- Getting stuck for _____ or ______ difficulties
- ________ things (names, dates, places)
- loss of (1)
- difficulty in solving (1) or performing (1)
- mis_____ things
- poor or decreased (1)
- changes in m_____, b_____, and overall p________
- Easily dis______, even in ______ surroundings
A
- Getting stuck for words or language difficulties
- Forgetting things (names, dates, places)
- Loss of interest in things previously interested in
- Difficulty in solving problems or performing everyday tasks
- Misplacing things
- Poor or decreased judgment
- Changes in mood, behavior, and overall personality
- Easily disorientated, even in familiar surroundings
13
Q
Alzheimers Behaviors and Psych
- (1), anxiety
- _____ty, _____ty, _____thy
- D______, H______
- S____-w____ changes
- S_________
- Ag______
- Important to also screen for depression using (1)
A
- Depression, anxiety
- Irritability, hostility, apathy
- Delusions, hallucinations
- Sleep-wake changes
- Sundowning
- Agitation
- Important to also screen for depression using Geriatric depression scale
14
Q
Anatomical Changes of the Brain
Mild/Moderate vs. Severe Alzheimers
A
- Shrinkage of hippocampus, Cortical shrinkage, Moderately enlarged ventricles
- Extreme shrinkage of hippocampus, Extreme shrinkage of cerebral cortex, Severely enlarged ventricles
15
Q
Lewy Body Dementia
- % of all dementias?
- Relatively earlier (2) degeneration
- Similar to _______ disease dementia
A
- 20% of all causes of dementia
- Occipital and Basal Ganglia degeneration
- Similar to Parkinson disease dementia
16
Q
Lewy Body Dementia Characteristics
- Progressive decline in N_______ functioning
- D_______, Le_____
- Lengthy periods of ______ into _____
- Disorganized ______
- Visual _______* or delusions
- Motor symptoms including muscle _____ and loss of (1)
- ________ is also common
A
- Progressive decline in Neurocognitive functioning
- Drowsiness, Lethargy
- Lengthy periods of staring into space
- Disorganized speech
- Visual hallucinations* or delusions
- Muscle rigidity, loss of spontaneous movement
- Depression is also common
17
Q
Lewy Body Dementia
Earliest symptoms (2)
A
Visuospatial and Executive
- Executive like balancing checkbook, visuospatial like climbing stairs
- Concerned for delirium on top of dementia
18
Q
Lewy Body Dementia Core Features
- ________ism
- Recurrent early (1)*
- Fl________ (clue: recurrent (1) evaluations)
- Suggestive features include (1) (dream enactment) & neuroleptic sensitivity
A
- Parkinsonism
- Recurrent early visual hallucinations
- Fluctuations (clue: recurrent DELIRIUM evaluations)
- Suggestive features include REM sleep disorder (dream enactment) & neuroleptic sensitivity
19
Q
Frontotemporal Dementia (FTD)
Arises from?
Originally known as?
Characterized by changes in (2) lobes that control (4)
A
Pathologic aggregates of Tau protein (TDP-43)
Pick’s disease
Frontal and Temporal lobes of the brain that control reasoning, personality, social behavior, and speech
20
Q
Frontotemporal Dementia Prevalence
Usually seen in what population?
Can you diagnose it with an MRI?
A
- Usually are YOUNG and need to screen for PSYCHIATRIC DISORDERS*
- MRI is not diagnostic but will show structural abnormalities can help indicate FTD vs. LBD vs. Alzheimers*
21
Q
Frontotemporal Dementia Characteristics
- FTD manifested by changes in (2)
- (2) change (may be initially misdiagnosed as a psychiatric disorder)
- E______ dysfunction
- Progressive non-fluent _______
- May see ____sonism or _____ weakness
A
- Behavior and Language
- Behavior and personality change (may be initially misdiagnosed as a psychiatric disorder)
- Executive dysfunction
- Progressive non-fluent aphasia
- May see parkinsonism or muscle weakness
22
Q
Vascular Dementia
=
“Evidence of (1) disease involving subcortical _____ matter”
- This finding is nondiagnostic and very _____ with age
- Changes may or may not be ______
- Don’t tell patients what?
A
Caused by multiple infarcts that lead to a disruption in blood flow to the brain
“chronic small vessel disease involving subcortical white matter”
- common with age
- may or may not be symptomatic
- Don’t tell patients “your scan showed strokes” - this is chronic small vessel/vascular dementia, not actual CVAs”
23
Q
Vascular Dementia
Suspect when
- Onset is (1) and/or (1) decline
- Course is (1)
- H/O (1)
A
- abrupt, stepwise decline
- fluctuating
- H/O stroke
24
Q
Vascular Dementia
Often associated with _______ dysfunction, ____ disorder, A_____, In_______
- Common presenting symptoms include
- C_______, ____ term memory deficits
- W_______, getting lost in ______ places
- Gait is (2)
- Loss of (2) control
- (2) inappropriately
- Difficulty following _______ and problems counting/making _____ transactions
A
Executive dysfunction, Gait disorder, Apathy, Incontinence
- Confusion, short term memory deficits
- Wandering, getting lost in familiar places
- Rapid, shuffling gait
- Loss of bowel and bladder control
- Laughing or crying inappropriately
- Difficulty following instructions and problems counting/making money transactions
25
What type of Dementia is this?
1. Gradual impairment in memory, functional status, and other areas of cognition
2. Plateaus in course of progression, associated depression, insomnia
Alzheimer's
26
What type of Dementia is this?
1. Sudden onset of cognitive impairment in setting of stroke and/or risk factors of stroke
2. Focal neurological signs on exam; neuroimaging evidence of previous stroke; presence of HTN, DM, CAD, ⇡ lipids
Vascular (multi infarct) Dementia
27
What type of Dementia is this?
1. Deficits in attention and executive function. Memory impairment may no be evident
2. Fluctuating cognition, recurrent visual hallucinations, motor features of parkinsonism, recurrent falls
Lewy Body Dementia
28
What type of Dementia is this?
1. Gait disorder mimicking Parkinson's, dementia, urinary incontinence
2. Shuffling, broad based gait, improvement following large volume spinal tap
Normal Pressure Hydrocephalus
*Normal pressure hydrocephalus - usually treated/cured with shunt placement, patient will get better*
29
Steps to take in Dementia Evaluation
* H\_\_\_\_\_
* P\_\_\_\_\_ and N\_\_\_\_\_\_ Exam
* C\_\_\_\_\_\_ Screening Test
* Rule out _______ Causes
* Neuro\_\_\_\_\_\_
* Consider the Et\_\_\_\_\_\_
* Treatment or R\_\_\_\_\_\_\_ *(**in NY there are many memory centers, but PCP may be required for basic labs and imaging)*
* History
* Physical and Neurological Exam
* Cognitive Screening Test
* Rule out Reversible Causes
* Neuroimaging
* Consider the Etiology
* Treatment or Referral *(**in NY there are many memory centers, but PCP may be required for basic labs and imaging)*
30
History Taking
* Patient will “\_\_\_\_\_” their memory problems
* Get history from ____ or \_\_\_\_\_, if possible.
* Memory impairment may be evidenced by repetitive \_\_\_\_\_\_, \_\_\_\_writing, _____ objects, etc
* Ask about ______ impairment
* Ask about (1) to assess functioning
* Dementia is not just (1)!
* Next step = _______ screening test
* Patient will “forget” their memory problems
* Get history from caregiver or spouse, if possible.
* Memory impairment may be evidenced by repetitive questioning, list writing, lost objects, etc
* Ask about memory impairment
* Ask about daily activities to assess functioning
* Dementia is not just memory impairment!
* Next step = cognitive screening test
31
Features Associated with Dementia
1. Ag\_\_\_\_
2. Ag\_\_\_\_\_\_\_\_
3. S\_\_\_\_\_ disturbances
4. A\_\_\_\_\_\_ (can be misdiagnosed as depression)
5. De\_\_\_\_\_\_ or an\_\_\_\_
6. P\_\_\_\_\_\_ changes
7. B\_\_\_\_\_\_ disinhibition
8. _______ insight
9. (1) (visual more common than auditory)
10. (1) (often paranoid or persecutory)
1. Agitation
2. Aggression
3. Sleep disturbances
4. Apathy (can be misdiagnosed as depression)
5. Depression or anxiety
6. Personality changes
7. Behavioral disinhibition
8. Impaired insight
9. Hallucinations (visual more common than auditory)
10. Delusions (often paranoid or persecutory)
32
ADLs
(6)
* Bathing
* Dressing
* Grooming
* Toileting
* Continence
* Transferring
33
IADLs
(7)
* Telephone
* Travel
* Shopping
* Meals
* Housework
* Medicine
* Money
34
PMH/Social
* M\_\_\_\_\_ problems and ____ factors
* Neurologic history (st\_\_\_\_, tr\_\_\_\_, in\_\_\_\_\_)
* Ed\_\_\_\_\_ background
* F\_\_\_\_\_\_ history
* Al\_\_\_\_ and d\_\_\_\_\_
* M\_\_\_\_\_\_\_\_
* *Remember, your first goal is to exclude (1)*
* Medical problems and risk factors
* Neurologic history (stroke, trauma, infection)
* Education background
* Family history
* Alcohol and drugs
* Medications
* *Remember, your first goal is to exclude readily treatable causes...*
35
Impaired Executive Function
* Difficulty with pl\_\_\_\_, in\_\_\_\_, sequencing, monitoring or stopping complex \_\_\_\_\_\_
* Contributes to loss of ________ activities of ADLs such as shopping, meal preparation, driving and managing finances
* Difficulty with planning, initiating, sequencing, monitoring or stopping complex behaviors
* Contributes to loss of instrumental activities of ADLs such as shopping, meal preparation, driving and managing finances
36
Importance of Cognitive Screening
* Establish a ______ level of functioning
* Allows for ______ documentation of cognition
* Cognitive Impairment is often?
* Establish a baseline level of functioning
* Allows for objective documentation of cognition
* Cognitive Impairment is often not documented
37
Screening Tests
* Mini-Mental State Exam (MMSE)
* Clock Drawing Test (CDT)
* Mini-Cog
* Time and Change
* 7-Minute Screen
* Montreal Cognitive Assessment (MoCA)
38
Mini Mental Status Exam
* O\_\_\_\_\_\_ (10 points)
* Re\_\_\_\_\_\_\_\_ (3 points)
* A\_\_\_\_\_\_ and Ca\_\_\_\_\_\_\_\_ (5 points)
* Re\_\_\_\_\_ (3 points)
* L\_\_\_\_\_\_\_ (8 points)
* V\_\_\_\_\_\_\_\_ (1 point)
* Total=\_\_\_, if less than \_\_\_\_, consider dementia*, \_\_\_-\_\_\_= moderate,*
* Orientation (10 points)
* Registration (3 points)
* Attention and Calculation (5 points)
* Recall (3 points)
* Language (8 points)
* Visuospatial (1 point)
* Total=30, if less than 25, consider dementia*, 13-20 = moderate, \<12 = severe*
39
Clock Drawing Test
Part of the (1)
There are certain times providers are suggested to use, ie (1)
Mini Cog
11 after 9
40
Mini Cog
=
* More sensitive than CDT
* Same advantages as CDT
* Not as commonly used as MMSE, but FAST
* Involves visuospatial, executive and planning, and memory functions
* “Positive” = ___ word recall/ ______ clock
Clock-Drawing + three item memory test
* More sensitive than CDT
* Same advantages as CDT
* Not as commonly used as MMSE, but FAST
* Involves visuospatial, executive and planning, and memory functions
* “Positive” = 2 word recall and/or abnormal clock
41
Potentially Reversible Dementias
* _____ Toxicity
* M\_\_\_\_\_\_ Disturbance
* Normal Pressure \_\_\_\_\_\_\_
* _____ Lesion (Tumor, Chronic Subdural- *often the pt that abuses drugs/alcohol and falls*)
* Infectious Process (Me\_\_\_\_\_\_, S\_\_\_\_\_\_\_)
* C\_\_\_\_\_\_\_\_- Vascular Disease (S\_ _ , Sarcoid)
* En\_\_\_\_\_\_ Disorder (Thyroid, Parathyroid)
* N\_\_\_\_\_\_\_ Disease (B12, thiamine, folate)
* Other (COPD, CHG, Liver Dz *check ammonia lvls*, Apnea)
* Drug Toxicity
* Metabolic Disturbance
* Normal Pressure Hydrocephalus
* Mass Lesion (Tumor, Chronic Subdural- *often the pt that abuses drugs/alcohol and falls*)
* Infectious Process (Meningitis, Syphilis)
* Collagen- Vascular Disease (SLE, Sarcoid)
* Endocrine Disorder (Thyroid, Parathyroid)
* Nutritional Disease (B12, thiamine, folate)
* Other (COPD, CHG, Liver Dz *check ammonia lvls*, Apnea)
42
Cognitive Decline
What is CJD?
*Creutzfeldt-Jakob disease* *(prion disease that is asctd with mad cow disease (eating bad meat) - outcome is usually poor, has a rapid decline)*
43
Types of Dementia
Types of Dementia
44
Labs for Dementia Workup
* E\_\_\_\_\_\_\_\_
* C\_ \_
* ______ Enzymes
* (1) hormone
* V ____ level
* S\_\_\_\_\_\_?
* Others only if clinical suspicion high
* Possible L \_
* Electrolytes
* CBC
* Liver Enzymes
* TSH
* B12 level
* Syphilis?
* Others only if clinical suspicion high
* Possible LP
45
Imaging
* Most Treatment Guidelines call for \_\_\_\_\_\_\_
* (1) usually adequate (*w/o contrast)*
* (1) if Vascular Dementia is suspected
* Most Treatment Guidelines call for Imaging
* CT usually adequate (*w/o contrast)*
* MRI if Vascular Dementia is suspected *\***MRI W/O contrast is first choice - however if pt has agitation, paranoia, underlying breathing problem, MRI may not be first choice or may require sedation however sedation or contrast requires collaboration*
46
Why Properly Diagnose?
* There may be a readily _______ cause
* Some degenerative dementias do have symptomatic pharmacotherapies
* Patients and ________ want to know and understand what they are dealing with
* Helps _____ term planning
* Facilitates re\_\_\_\_\_ efforts
* Facilitates advocacy/\_\_\_\_\_\_ group participation *(can call \_\_\_\_)*
* There may be a readily treatable cause
* Some degenerative dementias do have symptomatic pharmacotherapies
* Patients and families want to know and understand what they are dealing with
* Helps long term planning
* Facilitates research efforts
* Facilitates advocacy/support group participation *(can call 311)*
47
Drugs that Delay Clinical Decline
(1)
Drugs in this category may **delay clinical decline** with benefits to both (1) and (1) in people living with Alzheimer’s disease
**_Aducanumab (Aduhelm™)_**
benefits both cognition and function
48
**Aducanumab (Aduhelm™)**
**MOA**
Route, Frequency
* Beta Amyloid plaques disrupt _______ between _____ cells in the brain and may also activate ______ system cells that trigger _______ and ______ disabled nerve cells
**Anti-amyloid antibody that targets beta-amyloid protein that forms in the brain and accumulates into plaques**
IV infusion Q4 weeks
* Beta Amyloid plaques disrupt communication between nerve cells in the brain and may also activate immune system cells that trigger inflammation and devour disabled nerve cells
* $4500 per infusion, 60k/year, most insurances are covering this, you won’t be prescribing it but may have a pt on this and your notes will be reviewed by insurance (labs, screening) to see if they are covered*
49
Drugs that may treat Cognitive symptoms (memory and thinking)
**Rx (1)-(3)**
**MOA**
Treats what symptoms?
**_Cholinesterase inhibitors_**
Donepezil (Aricept®)
Rivastigmine (Exelon®)
Galantamine (Razadyne®)
* These medications prevent the breakdown of acetylcholine, a chemical messenger important for memory and learning. These drugs support communication between nerve cells.
* Treat symptoms related to memory, thinking, language, judgment and other thought processes.
50
Cholinesterase Inhibitors Indications
1. **Donezepil (Aricept) =**
2. **Rivastigmine (Exelon®) =**
3. **Galantamine (Razadyne®) =**
1. approved to treat all stages of Alzheimer’s disease
2. approved for mild-to-moderate Alzheimer’s as well as mild-to-moderate dementia associated with Parkinson’s disease
3. approved for mild-to moderate stages of Alzheimer’s disease
51
Cholinesterase Inhibitors SE
(4)
Nausea, Vomiting *(check K levels)*
Loss of appetite *(check albumin?)*
Increased frequency of bowel movements
52
Cholinergic Hypothesis
1. Cholinergic deficiency contributes to the (1) of AD
2. May contribute to behavior symptoms such as (4)
1. Cognitive decline
2. Behavior symptoms
1. Psychosis-agitation
2. Apathy-indifference
3. Disinhibition
4. Aberrant motor behavior
53
Glutamate Regulators
## Footnote
**Rx (1)**
**MOA**
**Indications**
**SE**
**Memantine (Namenda)**
Regulates the activity of glutamate, a different chemical messenger that helps the brain **process information**
Improves **memory, attention, reason, language** and the ability to **perform simple tasks.**
Headache, Constipation, Confusion and Dizziness.
54
Cholinesterase inhibitor + glutamate regulator
**Rx (1)**
Indication
**SE**
**Namzaric (Memantine + Donezepil)**
Approved for moderate-to severe Alzheimer’s disease.
Nausea, vomiting, loss of appetite, increased frequency of bowel movements, headache, constipation, confusion and dizziness
55
Suvorexant Belsomra®
Indication
SE
Insomnia in people living with mild to moderate Alzheimer’s disease
Impaired alertness and motor coordination, **worsening of depression or suicidal thinking**, **complex sleep behaviors, sleep paralysis, compromised respiratory function**
*With all of these medications - focus on the SE!*
56
Common Doses
1. Donezepil
2. Galantamine
3. Rivastigmine
4. Memantine
1. 5mg/day, 10mg/day target dose after 1m
2. 4mg BID, 24mg/day target dose, increase by 4mg BID every 1m
3. 1.5mg BID, 6-12mg target dose, increase by 1.5 BID every 1m
4. 5mg/day, 10mg BID target dose, increase by 5mg daily every week
57
Dementia Interventions
* Good assessment of \_\_\_\_/\_\_\_\_\_\_ situation
* _______ techniques first
* Psych meds should be start ____ and go ____ and _____ choice --- C\_\_\_\_\_\_/C\_\_\_\_\_\_\_
* Good assessment of home/institution situation
* Behavioral techniques first
* Psych meds should be start low and good slow and last choice --- CONSULT/COLLABORATE
58
Implementing Effective Interventions
* ______ Issues:
* Patients may mis\_\_\_\_\_\_\_ their surroundings and become f\_\_\_\_\_\_ of what is happening around them
* Physical and psychological ________ safety is a priority
* E\_\_\_\_\_\_\_ Management
* M\_\_\_\_\_\_\_ Management
* _______ Stress:
* Providing care for a family member with dementia can be highly stressful and overwhelming
* Family caregivers need to receive adequate preparation and support when caring for the individual
* Safety Issues:
* Patients may misinterpret their surroundings and become fearful of what is happening around them
* Physical and psychological environmental safety is a priority
* Environmental Management
* Medication Management
* Caregiver Stress:
* Providing care for a family member with dementia can be highly stressful and overwhelming
* Family caregivers need to receive adequate preparation and support when caring for the individual
59
Behavioral Treatment
(6)
* Refer to Adult Day Care
* Respite/Adult Family Homes
* Caregiver Support Groups
* Psychoeducation
* Depression in caregiver
* SNF before crisis
60
Next Steps: Prepare for Chronic Care
* **\_\_\_\_\_\_\_\_ philosophy** from **d\_\_\_\_\_\_ to d\_\_\_\_\_\_,** since dementia is a…
* Pr\_\_\_\_\_\_ indicator
* R\_\_\_\_\_ indicator
* *Ave life expectancy **-**\_ years*
* *Care is \_\_\_\_\_\_-specific*
* *Components of palliation vary over time*
* *Care is always a c\_\_\_\_\_\_\_\_*
* You, the patient, and the family
* A medical _______ specialist, when needed
* A p\_\_\_\_\_\_\_\_ care manager, especially at moderate dementia stages and beyond, or when families are stressed
* **Palliative philosophy** from **diagnosis to death,** since dementia is a…
* Prognostic indicator
* Risk indicator
* *Ave life expectancy 4.8-10 years*
* *Care is stage-specific*
* *Components of palliation vary over time*
* *Care is always a collaboration*
* You, the patient, and the family
* A medical dementia specialist, when needed
* A psychosocial care manager, especially at moderate dementia stages and beyond, or when families are stressed
61
Diagnosing Dementia and Clarifying Goals of Care
62
Fast Scoring Dementia
Scale (1)
Functional Assessment Scale (FAST)
63
Consult/Collaborate
* ______ onset (
* Presentation is \_\_\_\_\_\_
* If severe \_\_\_\_\_sonism, f\_\_\_\_\_ findings, or abnormal \_\_\_\_\_
* Behaviors seemingly “un\_\_\_\_\_\_”
* To better document severity, consider n\_\_\_\_\_\_\_\_\_\_
* Early onset (\<60)
* Presentation is atypical
* If severe parkinsonism, focal findings, or abnormal scan
* Behaviors seemingly “untreatable”
* To better document severity, consider neuropsychologist
64
What is Delirium?
1. Onset
2. Duration
3. Course
4. Impaired (2)
5. (2) presentations
6. Cannot be explained by?
7. Reversibility
1. **Acute**
2. **Hours-Days**
3. Consciousness level **fluctuates** over the course of the day
4. Reduced clarity in patient's **awareness** of the environment, with impaired ability to focus, sustain, or shift **attention**
5. The patient may be **agitated**, **irritable**, and **emotionally labile** or **drowsy**, **quiet**, and **withdrawn**
6. Cannot be explained by a patient's preexisting, established, or evolving dementia.
7. Delirium is _conceptualized as a reversible illness,_ except in the last 24 to 48 hours of life
65
Delirium Prevalence
* 1/\_\_ of general medical patients who are ___ years of age or older have delirium.
* Delirium is the most common ______ complication among older adults, with an incidence of 15-25% after major (1) surgery and 50% after high-risk procedures such as (2).
* Among patients undergoing (1) in ICU, the cumulative incidence of delirium, when combined with stupor and coma, exceeds 75%.
* Delirium is present in 10-15% of older adults in the (1).
* The prevalence of delirium at the end of life approaches 85% in _______ care settings.
* *Delirium in a primary care setting needs?\**
* 1/3 of general medical patients who are 70 years of age or older have delirium.
* Delirium is the most common surgical complication among older adults, with an incidence of 15-25% after major elective surgery and 50% after high-risk procedures such as hip-fracture repair and cardiac surgery.
* Among patients undergoing mechanical ventilation in ICU, the cumulative incidence of delirium, when combined with stupor and coma, exceeds 75%.
* Delirium is present in 10-15% of older adults in ED.
* The prevalence of delirium at the end of life approaches 85% in palliative care settings.
* *Delirium in a primary care setting needs an ACUTE EVAL, hospital home, ER, or inpatient*
66
Hyperactive vs. Hypoactive Delirium
1. Which type represents only 25% of cases, describe it?
2. Which type has a poorer prognosis, why?
1. Hyperactive delirium, described as agitated with the others having hypoactive (“quiet”) delirium.
2. Hypoactive delirium is associated with a poorer prognosis, potentially because it is less frequently recognized*.* *(higher risk of infection, immobility, skin breakdown)*
67
Hyperactive vs. Hypoactive Delirium Chart
Fill in the blanks
68
Predisposing factors for Delirium
* _____ age
* D\_\_\_\_\_\_ (often not recognized clinically)
* F\_\_\_\_\_ disabilities
* ____ sex
* Poor (2) senses
* D\_\_\_\_\_\_ symptoms
* Mild ______ impairment
* A\_\_\_\_\_ abuse
* Older age
* Dementia (often not recognized clinically)
* Functional disabilities
* Male sex
* Poor vision and hearing
* Depressive symptoms
* Mild cognitive impairment
* Alcohol abuse
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Precipitating Factors of Delirium
* Drugs (especially sedative (2))
* S\_\_\_\_\_\_/An\_\_\_\_\_
* High _____ levels
* An\_\_\_\_\_
* In\_\_\_\_\_\_\_
* Acute (1) or (1)
* R\_\_\_\_\_\_\_ could be an etiologic factor or a proxy for severity
* Drugs (especially sedative hypnotic agents and anticholinergic agents) ▪
* Surgery/anesthesia
* High pain levels
* Anemia
* Infections
* Acute illness, or acute exacerbation of chronic illness
* Restraints could be an etiologic factor or a proxy for severity
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Delirium History Cont.
* Other symptoms Ie (2), (1) weakness
* A thorough ______ review is required for all patients with delirium
* Consumption of (1) and the use of (1) drugs, dietary supplements
* Other symptoms(e.g., dyspnea and dysuria), focal weakness
* A thorough medication review is required for all patients with delirium
* Consumption of alcohol and the use of nonprescription drugs, dietary supplements
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Beers Criteria
High Risk Drugs in Delirium
**(11)**
**BONAAAATHAB**
1. Benzodiazepines
2. Opioid analgesics (especially meperidine)
3. Nonbenzodiazepine sedative hypnotics (ie zolpidem)
4. Antihistamine (1st gen sedating agents doxylamine and diphenhydramine)
5. Alcohol
6. Anticholinergics (oxybutynin, benztropine)
7. Anticonvulsants (primidone, phenobarbital, barbital, phenytoin)
8. Tricyclic antidepressants (especially tertiary amines - amitriptyline, imipramine, doxepin)
9. Histamine H2 receptor blockers
10. Antipsychotics (especially low potency typical antipsychotics like chlorpromazine and thioridazine)
11. Barbiturates
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Delirium
* The first step in delirium management is accurate _____ using (1)
* After receiving a diagnosis of delirium, patients require a _thorough evaluation for ______ causes_ all correctable contributing factors should be addressed.
* The first step in delirium management is accurate diagnosis; a brief validated instrument that assesses features in the Confusion Assessment Method algorithm is recommended.
* After receiving a diagnosis of delirium, patients require a _thorough evaluation for reversible causes_; all correctable contributing factors should be addressed.
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CAM Diagnostic
* Only \_\_\_-\_\_\_% of delirium cases are recognized.
* Systematic reviews support the **(1)** as the most useful bedside assessment tool.
* The CAM algorithm establishes the diagnosis of delirium according to the presence or absence of **(4) features**
* Only 12 to 35% of delirium cases are recognized.
* Systematic reviews support the Confusion Assessment Method (CAM) as the most useful bedside assessment tool.
* The CAM algorithm establishes the diagnosis of delirium according to the presence or absence of four features:
1. **acute change in mental status with a fluctuating course**
2. **inattention, and either**
3. **disorganized thinking or an**
4. **altered level of consciousness.**
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Differential Diagnosis for Delirium
* **(3)\*** should all be considered in the differential diagnosis for delirium. These syndromes often co-occur, patients may have more than one.
* In the absence of clear documentation from medical records or reports from family members that the patient’s mental status is consistent with his or her baseline, _it is always safest to?._
* Reports of an ____ change in _____ status, witnessed ______ over a period of minutes to hours, or an abnormal level of _______ fulfill CAM criteria and make delirium more likely.
* **Dementia, depression, and acute psychiatric syndromes(mania)** should all be considered in the differential diagnosis for delirium.These syndromes often co-occur, patients may have more than one.
* In the absence of clear documentation from medical records or reports from family members that the patient’s mental status is consistent with his or her baseline, _it is always safest to assume delirium._
* Reports of an acute change in mental status, witnessed fluctuations over a period of minutes to hours, or an abnormal level of consciousness fulfill CAM criteria and make delirium more likely.
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Causes of Delirium
* **D**
* **E**
* **L**
* **I**
* **R**
* **I**
* **U**
* **M**
* **D**: Drugs (opioids, anticholinergics, sedatives, steroids, benzodiazepines, chemotherapy and immunotherapies, some antibiotics)
* **E:** Eyes and ears (poor vision and hearing, isolation)
* **L**: Low flow states (hypoxia, MI, HF, COPD, shock)
* **I**: Infections
* **R**: Retention (urine/stool), restraints
* **I**: Intracranial (CNS metastases, seizures, subdural, CVA, hypertensive encephalopathy)
* **U**: Underhydration, undernutrition, undersleep
* **M**: Metabolic disorders (sodium, glucose, thyroid, hepatic, deficiencies of vitamin B12, folate, niacin, and thiamine) and toxic (lead, manganese, mercury, alcohol)
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Labs for Delirium
* C\_\_\_, B\_\_\_, \_\_\_\_FTs, \_\_\_SH and C\_/S, Vitamin \_\_
* Tests that are routinely required include a (2)
* Chest \_\_\_\_\_, and ____ are also often helpful
* Additional tests that are useful in select situations include
* blood and urine \_\_\_\_\_\_studies,
* blood \_\_\_\_\_,
* (1) (if hypercapnia is suspected)
* (1) (in patients with head trauma or new focal neurologic findings)
* (1) (if findings suggest meningitis or encephalitis)
* (1) (if seizures are suspected)
* CBC, BMP, LFTS, TSH, UA and C/S Vitamin B12
* Tests that are routinely required include a CBC and BMP
* Chest radiography, and EKG are also often helpful
* Additional tests that are useful in select situations include
* blood and urine toxicology studies
* blood cultures, ABG (if hypercapnia is suspected)
* cerebral imaging (in patients with head trauma or new focal neurologic findings)
* LP (if findings suggest meningitis or encephalitis)
* EEG (if seizures are suspected)
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Medications for Delirium
(6)
Haloperidol
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Lorazepam
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Delirium Key Points
* **Is patient with delirium dis\_\_\_\_\_\_ or are a ____ to themselves or others:**
* **Avoid drugs with anti\_\_\_\_\_\_activity, is associated with worsening delirium.**
* **For hypoactive delirium, especially where agitation is not overt and delirium may not be recognized, _____ dosing is recommended.**
* **OUTPATIENT NEEDS \_\_\_\_\_**
* **Is patient with delirium distressed or are a risk to themselves or others:**
* **Avoid drugs with anticholinergic activity. Anticholinergic activity is associated with worsening delirium.**
* **For hypoactive delirium, especially where agitation is not overt and delirium may not be recognized, scheduled dosing is recommended.**
* **OUTPATIENT NEEDS EVAL**
