delirium and dementia: the best of friends, the worst of enemies · 2019-01-23 · reversible...
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Delirium and dementia: The best of
friends, the worst of enemies
David Meagher
Professor of Psychiatry, UL Graduate-Entry Medical School
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Two Sumo Wrestlers
Two great heavyweights
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Generalised Cognitive Disorders
Delirium Dementia
Acute Subacute Insidious
Reversible Chronic progressive
1. Acute onset / fluctuating course 2. Prominent Inattention with reduced awareness 3. Generalised cognitive impairment 4. Underlying etiology
? Overly
simple
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0
500
1000
1500
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1 2 3 4
Medline citations between 1980 and 2000
Dementia
Delirium
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? Parallel Universes
Dementia Research
Delirium Research
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MEDLINE CITATIONS WITH ‘DELIRIUM’ IN THE TITLE (1995-2012)
100
300
500
700
900
1100
1300
1500
1995
-96
1997
-98
1999
-200
0
2001
-02
2003
-04
2005
-06
2007
-08
2009
-10
2011
-12
Updated: Meagher, Int Rev Psych 2009
So what have we Learned and how is it relevant to dementia?
EDA
ADS
IDS
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1. Delirium is common (and common in dementia)
Key Findings
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Siddiqi (2005): SR 42 Studies
Prevalence at admission 10-31% Incidence during admission 3-29% Overall freq per admission 11-42%
One in
five
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CUH 36 hour point prevalence
358 inpatients
311 assessed
142 cog problems*
55 DSM IV
Delirium
47 Excluded
Coma / stupor /
severe dysphasia
Actively dying
Infectious risk
Refused n < 10
Psychiatry / paediatrics
169
‘cognitively
intact’
55% comorbid dementia
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2. Delirium is prognostically bad
Key Findings
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Delirium linked to poor outcomes….
LOS: Doubled
‘New’ LTCI c30%%
Costs of care: Doubled
Reduced subsequent
functional status 3x less likely to return ‘home’
Increased subsequent
‘new’ dementia Diagnosis 3x increase in following year
Mortality
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AND DON’T FORGET… Mortality
Increased
by 11 %
for every
additional
48 hours
of delirium
Gonzalez et al, 2009
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Poor outcomes
Delirium impacts independent of
- Age
- Frailty
- Comorbidity severity
- Dementia status
And predicted by
- severity of delirium symptoms
- complications of uncontrolled delirium
Delirium itself is a major cause
of the poor outcomes
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Cognitive
Superbug?
One in five hospitalised patients
have a condition that is independently
linked to poor outcomes
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3. Delirium and dementia have a complex bidirectional relationship
Key Findings
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What do we know about the relationship
between delirium and dementia?
High co-morbidity (50% delirium also dementia; >50% dementia sufferers experience
delirium if hospitalised) AND a bad combination (dementia patients who develop
delirium have 25% mort within 30 days)
Misdiagnosis common
Increased risk of subsequent dementia (x3 in year after episode;
eight-fold in older patients)
? Harbinger vs accelerant or even causal
Persistent cognitive impairment (LTCI)
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Jackson et al (2004) &
Maclullich et al (2009)
18 studies of LTCI post delirium with c 4000 patients
Clear link between delirium and LTCI
(30% of older patients)
LTCI occurs in patients deemed
cognitively intact pre-delirium
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Cognitive Trajectories of
Alzheimer disease patients
with and without delirium
Information-Memory-
Concentration (IMC) :
decline before (2.5 pts / yr)
vs after (4.9 points / year)
i.e. Doubling of rate of
progression
Fong et al (2009)
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Direct toxic effect
of delirious state Dysregulation of stress and
inflammatory responses
Neurotoxic
effects
of delirium
complications
Neurotoxicity
of medications
Neurotoxicity of underlying etiologies
Unresolved,
prolonged, or
recurrent delirium
Progression or
acceleration of
preexisting
cognitive decline
Maclullich et al, Int Rev Psychiatry 2009
Persistent Cognitive Deficits Following
Delirium Episode: Possible Mechanisms
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Is delirium the most
preventable known risk factor
for dementia?
Either way – better delirium care = better dementia outcomes
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4. Delirium is poorly identified and inconsistently managed
Key Findings
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Delirium is one of the worst
managed common conditions in
modern healthcare systems
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Missed, misdiagnosed, diagnosed late…
Elie et al (2000) Elderly ER attenders: 65% missed
Kishi et al (2007) Gen hosp Psych referrals: 46% missed
Han et al (2009) Elderly ER attenders: 76% missed
Collins et al (2010) elderly med admission : 72% missed
Fang et al (2008) Pall care patients: 55% missed
Ryan et al (2013) Gen hosp point prevalence: 56% missed
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Non-pharmacological management of delirium
Educate patient and family/carer on delirium and prognosis
Involve family/carer in hospital care routine
Reorientation and reassurance strategies
Normalise sleep patterns
Prevent complications- e.g. falls, constipation
Ensure adequate hydration
Ensure pain relief is adequate
Encourage activity- mobility and ADLs
Use visual/ hearing aids to facilitate communication
Nurse with familiar staff in relaxed environment
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Treatment
Modest evidence for both pharmacological and environmental approaches to both prevention
and treatment…..NICE guidelines (2010)
Guidelines vary in their emphasis – inconsistent application - reflecting perceived risk-benefit balance in different populations: pall care / ICU versus elderly medicine
Pharmacological evidence mainly for APs: 32 prospective studies but only 2 placebo-controlled- 2/3 patients respond within a week (Meagher et al, 2013)
Response to pharmacological and non-pharmacological interventions is diminished if comorbid dementia – coupled with increased risk of Adverse effects…….?net value
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5. Complex problems rarely respond to simple solutions
Key Findings
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Simple (e.g. Educational) interventions don’t endure
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Education and Awareness
Efficient Detection Tools
Effective Interventions
Penetration of policy, guidelines and real world protocols & procedures
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European Delirium Association 9th Annual Meeting.
www.europeandeliriumassociation.com