confusion in the older adult: delirium and dementia

Dr. Chr is t ine Tomkinson, BSc BMBSAdul t Neuro logy Res ident ,

McMaster Univers i tyOntar io , Canada

Confusion in the Older Adult

76 yr old woman with confusion…

Focused Medical History Duration? Constant or fluctuating? ROS – fever, malaise, cough,

dysuria, recent trauma

76 yr old woman with confusion…

Past Medical History Previous similar episodes? Known dementia diagnosis?

If so, what’s different today?

76 yr old woman with confusion…

Medications List of medications; any recent changes? Who controls meds and how are they given (blister

pack, etc) Any concerns with med administration? Look at meds – more/less than expected?

76 yr old woman with confusion…

Social History Who lives with her? Recently widowed? Social outlets? Diet, alcohol use

Delirium

Disturbance in consciousness, with reduced ability to focus, sustain, or shift attention

Change in cognition or development of a perceptual disturbance

Disturbance develops over short period of time (hrs to days)

Fluctuates during course of dayCaused by a medical condition, substance

intoxication or medication side effect

Why do we care?

10-15% prevalence in general medical/surgical in patients

Approx 30% of older patients during a hospital stay

60-70% in ICU80-90% palliative care

Increased length of hospital stay, institutional discharge, mortality

Clinical Features

D – Disordered thinkingE – Euphoria, Emotions (fearful, depressed,

angry)L – Language impaired (dysarthia, dysnomia)I – Illusions, delusions, hallucinationsR – Reversal of sleep-wake cyclesI – Inattention/Distractible U – Unaware and disorientedM – Memory deficits

Causes of Delirium - DIMS

Drugs New medications, Interactions Overdose/Withdrawal Side effects **Anticholingerics Poisons

Causes of Delirium - DIMS

Infectious/Inflammatory Sepsis Meningitis/Encephalitis UTI/Pneumonia/Cellulitis

Causes of Delirium - DIMS

Metabolic Electrolyte disturbance Hyper/Hypo-glycemia Hypercarbia Hypoxemia Endocrine – Thyroid, Parathyroid, Pituitary, Adrenal Systemic organ failure – Liver/Renal Nutritional – Wernicke’s (Thiamine), B12, Folate

Causes of Delirium - DIMS

Structural Head injury – SAH, SDH Stroke, Seizure Space occupying lesion – Neoplasm, Abscess

Risk Factors

Predisposing Factors Precipitating Factors

Underlying brain diseases (dementias)

Polypharmacy

Advanced age Infection

Sensory impairment Dehydration

Immobility

Malnutrition

Catheter use

Hospitalization/Nursing home

Dementia

Development of multiple cognitive deficits Memory impairment At least one of:

Aphasia Apraxia Agnosia Disturbance in executive function

Gradual onset and progressive decline

Epidemiology

Estimated 35.6 million people worldwide (2010)

Total projected to double every 20 years In Middle East and North African countries, projected

increase of 125%

Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization report. Alzheimers Res Ther, 2012. 4(5)

Epidemiology

Approx 15% over age 65Incidence doubles every 10 years after 6050% prevalence over age 90Prevalence increased in Down Syndrome and

head injury (AD)

Types of Dementia

Alzheimer’s Disease – 60-80%

STM loss (anterograde amnesia) Loss of visuospatial skills, insight, executive

functioning, apraxia Vascular Dementia (multi-infarct) – 10-20%

Abrupt onset and stepwise deterioration Focal findings/Deficits specific to area affected May have vascular risk factors or stroke history

Mixed

Types of Dementia

Frontotemporal Dementia – 10%

Disinhibition, socially inappropriate Emotional lability Progressive expressive aphasia Memory preserved

Lewy Body Dementia – 15-25%

Fluctuating cognition/attention with progressive decline

Visual hallucinations Parkinsonism

Parkinson’s related Dementia

Reversible Dementia

Normal Pressure hydrocephalusVitamin deficiencies

Wernicke-Korsakoff’s (Thiamine – EtOH) B12, Folate

MedicationsThyroid dysfunctionHypo/Hyper-glycemiaCortisolDepressionHeavy metals

So what should you check?

Collateral history from family memberVital signs

Temperature Glucose SpO2

GEMS Diamond

Management of a Confused Adult

Well-lit, quiet roomGet down to the patient’s levelHearing aids/GlassesReverse stethoscope if neededTalk slowly, clearly and use plain language

Management of a Confused Adult

Give them time to process questionsOrient and re-orient; use family membersAvoid restraints, catheters, linesStop unnecessary medsTreat underlying causes

References

Atia M, Rastin T, and Scott C. Neurology. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc., Toronto 2011. p.10-15.

VIHA. CAM v3 Delirium in the older person: a medical emergency. www.viha.ca/mhas/resources/delirium/ (Accessed June 30,2014)

Francis J and Young GB. Diagnosis of delirium and confusional states. In: UpToDate, Wilterdink JL (Ed), UpToDate, Waltham, MA. (Accessed June 26, 2014).

Harrington, C.J. and K. Vardi, Delirium: presentation, epidemiology, and diagnostic evaluation (part 1). R I Med J (2013), 2014. 97(6): p. 18-23.

Hake AM and Farlow MR. Clinical features and diagnosis of dementia with Lewy bodies. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed July 1, 2014).

Holiff J, White M, and Wilson KR. Psychiatry. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc, Toronto 2011. p.17-19.

Shadien MF and Larson EB. Risk factors for cognitive decline and dementia. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed June 30,2014).

World Health Organization. Dementia: A public health priority. WHO Press, Geneva 2012.

Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization report. Alzheimers Res Ther, 2012. 4(5): p. 40.

Wright CB. Etiology, clinical manifestations, and diagnosis of vascular dementia. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed July 1, 2014).