Delirium Dementia Objectives To recognize delirium dementia To

Delirium & Dementia 神經內科 洪國華

Objectives • To recognize delirium & dementia • To understand the etiologies of delirium & dementia • To manage patients with delirium or dementia effectively

Outline • Introduction to Confusion • Delirium – – – Identifying underlying medial conditions Symptomatic treatment Environmental interventions • Dementia – – – Diagnosis Identifying treatable dementia Effective management of dementia

Consciousness • Definition: Awareness of self and environment • Ascending reticular activating system Arousal • Cerebral cortex Awareness

Levels of Consciousness • Alert • Drowsiness (Lethargy) – Conversant but sleepy and inattentive • Stupor – Incomplete arousal to painful stimuli • Coma – No verbal or complex motor response to any stimuli

Confusion • Decline in cognitive ability • May be acute →Delirium • May be chronic and progressive →Dementia • May be chronic and stationary →Mental retardation

Until another cause is identified, the confused patient should be assumed to have delirium, which is often reversible with treatment of the underlying disorder

Delirium • Synonyms – Acute encephalopathy – Altered mental status – Acute confusional state • Defined as the inability to maintain normal thought processes, including orientation, memory encoding and recall, and logical reasoning

Indicators Suggesting Delirium • • • Acute change in mental status Presence of medical illness Visual hallucinations Fluctuating levels of consciousness Acute onset of psychiatric symptoms without prior history of psychiatric illness • Acute onset of new or different psychiatric symptoms with history of prior psychiatric illness • Patient described as "confused" or "disoriented"

Delirium 5 -10% of all acute medical admissions have some degree of confusion • Usually due to multiple contributing factors • Treatment is aimed at correcting the underlying abnormality

Causes of Stupor or Coma (AEIOU tips) • • • Alcohol Epilepsy Insulin Overdose Uremia (and other metabolic causes) Trauma Infection Structural intracranial disorders Psychiatric Toxic or metabolic disorders Psychiatric disorders Stroke 33% 66% 1%

Causes of Delirium (AEIOU tips) • • • Alcohol (Delirium tremens) Epilepsy Insulin Overdose / Withdrawal / Side effects of drugs Uremia (and other metabolic causes) Trauma / Tumor Infection (CNS or systemic) Psychiatric Stroke Delirium is a medical emergency!

Common causes • • • • Intoxication (e. g. alcohol) Drug use Infection Electrolyte imbalance Hypoglycemia or hyperglycemia Renal impairment Cerebral ischemia Hypoxia Hepatic impairment Head injury Dementia Nutritional deficiency Alcohol or drug withdrawal Delirium is a medical emergency!

Rare causes • Intracranial space-occupying lesions • Hypertensive encephalopathy • Hormonal abnormalities such as hypo- or hyper-thyroidism

Serious causes • • • Meningitis (viral and bacterial) Encephalitis Chronic or acute subdural hematoma Subarachnoid hemorrhage Cerebral infarction Myocardial infarction in elderly

Questions to ask • Have the patient been taking any medication or drugs? • How did the confusion progress, over hours, days, weeks, or months? • Fever or headache? • Does the patient usually have memory or thinking problems (dementia)? • Do the patient have a history of seizures?

Examination • • • Fever or neck stiffness? Any mental status deficit? Is there a neurologic deficit? Is there any evidence of trauma? Are there any cardiac and other vascular disease, endocrine abnormalities, signs of infection?

Fever or neck stiffness? • • Grading of neck stiffness Brudzinski’s sign Kernig’s sign Meningeal signs are not reliable if comatose or being sedated

Any mental status deficit? • • • Judgment Orientation (time, place, person) Memory (short term, long term) Abstract thinking Calculation (serial subtraction) Speech

Is there a neurologic deficit? • • Level of consciousness Confrontation or visual threat test Extra-ocular movement Facial muscles Soft palate movement Pronator drift and leg raising test Tandem gait Reflexes (DTR, plantar response, primitive reflexes)

Is there any evidence of trauma? • Duration of initial loss of consciousness, retrograde and antegrade amnesia • Otorrhea or rhinorrhea? • Racoon eyes or battle sign?

Are there any cardiac and other vascular disease, endocrine abnormalities, signs of infection? • Congestive heart failure, chronic obstructive pulmonary disease, diabetic ketoacidosis, myocardial infarction, postoperative state, urinary tract infection, and pneumonia are just some of the conditions which predispose to acute confusional state in the absence of focal neurological deficit

Interventions • • Airway, Breathing, Circulation Intravenous line Finger stick glucose measurement (Surestep) Blood test – – BUN, Cr, Glucose, Na, K, Cl, Ca, Mg, IP GOT, GPT, NH 3 Arterial blood gas CBC, DC, Plt, PT, a. PTT • Foley catheterization in case of urine retention

Diagnostic Testings • • • CBC, differential count, platelets Serum glucose, electrolytes, calcium, magnesium, phosphorus Renal function tests Hepatic function tests, NH 3 Arterial blood gases Urine for urinalysis and toxicology studies EKG CT scan Thyroid function studies Cortisol level Lumbar puncture EEG

Management of Delirium • Identifying underlying medial conditions • Symptomatic treatment • Environmental interventions

Identifying Underlying Medial Conditions • • • Alcohol (Delirium tremens) Epilepsy Insulin Overdose / Withdrawal / Side effects of drugs Uremia (and other metabolic causes) Trauma / Tumor Infection (CNS or systemic) Psychiatric Stroke

Symptomatic Treatment • Haloperidol (Haldol) – For acute psychosis – 2 -10 mg (0. 5 -2 mg in the elderly) given two to three times per day • Risperidone (Risperdal) – For patients with dementia – 0. 25 to 3 mg per day • Quetiapine (Seroquel) – For patients with parkinson’s disease – 12. 5 to 200 mg per day

Environmental Interventions • Provide support and orientation • Provide an unambiguous environment • Maintaining competency Adapted from Meagher DJ. Delirium: optimising management. BMJ 2001; 322: 146.

Provide Support and Orientation • Communicate clearly and concisely; give repeated verbal reminders of the day, time, location, and identity of key persons (e. g. , members of the treatment team & relatives) • Provide clear signposts to patient's location, including a clock, calendar, and chart with the day's schedule • Place familiar objects from patient's home in the room • Ensure consistency in staff (e. g. , a key nurse) • Use television or radio for relaxation and to help the patient maintain contact with the outside world • Involve family members and caregivers to encourage feelings of security and orientation

Provide an Unambiguous Environment • Simplify care area by removing unnecessary objects • Consider using private room to aid rest and avoid extremes of sensory experience • Avoid using medical jargon in patient's presence • Ensure that lighting is adequate; provide a 40 - to 60 -watt night light to reduce misperceptions • Control sources of excess noise (e. g. , staff, equipment, visitors) • Maintain moderate room temperature

Maintaining Competency • Identify and correct sensory impairments (ensure patients have their glasses, hearing aids, dentures and consider whether interpreter is needed) • Encourage self-care and participation in treatment (e. g. , ask patient for feedback on pain) • Arrange treatments to allow maximum periods of uninterrupted sleep • Maintain activity levels: ambulatory patients should walk three times daily; nonambulatory patients should undergo full range of movement exercise for 15 minutes three times daily

Clinical pearls • Most patients with acute confusional states improve, but not completely • Prognosis depends on the cause of the confusion • Many elderly patients with delirium have a developing dementia which may be more obvious to the physician and family after resolution of the acute event

可治療型失智症 D drugs E emotional illness M metabolic & endocrine disorders E eye and ear problems N nutritional T tumour or trauma I infection A alcoholism

Vascular Dementia is not likely to be due to vascular causes if the total score is 4 or less; dementia is likely to be due to vascular causes if the total score is 7 or more Modified Hachinski Ischemia Score • Abrupt onset • Stepwise progression • Fluctuating course • Nocturnal confusion • Relative preservation of personality • Depression • Somatic complaints • Emotional incontinence • History of hypertension • History of stroke • Focal neurologic signs • Focal neurologic symptoms Points 2 1 2 1 1 2 2 2

Summary • Introduction to Confusion • Delirium – Identifying underlying medial conditions – Symptomatic treatment – Environmental interventions • Dementia – Diagnosis – Identifying treatable dementia – Effective management of dementia