534 Clin Med IV (Delirium, Dementia)

What is an acquired disorder characterized by a progressive decline in intellectual function?

What is most commonly affected?

What must be present for a diagnosis?

Dementia

Episodic memory

1+ cognitive deficit which interferes with ADLs (not due to delirium)

How does the DSM-V categorize dementia?

Major neurocognitive disorder

How often does the prevalence of dementia double?

What is the most common cause?

What is the most common type?

Every 5 years

Aging

Alzheimer's (2/3)

How will a patient with dementia present? (5)

What may occur in late stage disease?

Progressive recent memory loss (losing things, missed appts)

Personality changes (agitation, restless)

Impaired language, executive function

Depression

Impaired gait

Bed bound (pressure ulcers, malnutrition, dehydration)

T/F: There are medications which delay the progression of cognitive impairment in dementia

False

What are two characteristics of Alzheimers dementia?

How will a patient present?

Amyloid Plaques + Neurofibrillary Tangles

Recent memory loss

Apathy

Irritability

Aphasia

Delusions/Paranoia

Type of dementia caused by infarcts and atherosclerosis which can be sudden onset or a stepwise decline?

What is the best predictor of cognitive impairment?

What must there be evidence of?

Is this type more or less severe compared to others?

Clinical presentation?

Vascular

Lacunar infarts

Cerebrovascular disease (clinical or radiographic evidence)

Less

Impaired recall but better recognition

Type of dementia involving spherical eosiniphillic intraneuronal inclusions surrounded by a clear halo?

What accompanies the cognitive changes?

What other symptoms may be present?

Lewey Body

Movement disorder (Parkisonism)

REM disorder, visual hallucinations

What are the two variants of frontotemporal dementia?

When does this onset?

Behavioral -> changes in personality sparing memory

Language -> progressive non-fluent aphasia

Earlier (50s)

What is recommended in those with suspected cognitive impairment?

What two tools may be used?

Screening

MOCA, Mini-Cog

What imaging do we get for dementia?

What six labs should we assess for reversible causes?

CT (+/- MRI)

TFTs, B12, RPR, HIV, heavy metals, LFTs

What agents do we use to treat dementia?

What NMDA antagonist can we use alone or in combination?

What recombinant monoclonal antibody can we use?

What vitamin may be used?

Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine)

Memantine

Aducanumab

Vitamin E

What else must we consider regarding dementia treatment?

Accommodate behaviors (routine, distract)

Caregiver support

What agents can we use for neuropsychiatric behaviors in dementia, but can increase mortality and QT prolongation?

What agent can be used to treat agitation in dementia?

SGAs (risperidone, olanzapine, quetiapine, aripripazole)

Citalopram

Patients with moderate to severe dementia should not do what?

What advanced planning is needed?

Drive

Financial

What is the life expectancy for dementia?

Which type has a more rapidly declining course?

What is considered a terminal illness?

3 to 15 years

Lewy Body

End-stage

What is the problem with depression in elderly patients?

Unlike dementia, depression is what?

What does the incidence of depression increase with?

May not admit to depressed mood

Treatable

Aging

What does depression in the elderly present with?

What type of symptoms are likely to be present?

Somatic symptoms (insomnia/hypersomnia, fatigue, concentration, decreased appetite)

Psychotic

What must be present for a diagnosis of depression?

What is the time criteria for diagnosis?

What accompanying symptoms are likely to be present?

Depressed Mood or Loss of Interest

2 weeks

Sleep, appetite, fatigue

What is highly sensitive for detecting depression in the elderly?

2 Question Screen:

Have you felt depressed or hopeless in the last 2 weeks?

Have you felt little interest or pleasure in doing things?

What is the first line for depression treatment?

What can be used to treat concomitant appetite issues?

What can be used to treat concomitant neurologic pain?

SSRIs (citalopram, sertraline)

Mirtazapine

Duloxetine

Start low and go slow

How long do we treat depression for before switching medications?

How long do we continue treatment following remission since recurrence is common?

6 weeks

6 months

What is the non-pharmacologic treatment for depression?

When do we refer or admit these patients?

CBT, lifestyle (socialize, exercise, reduce alcohol)

SI, catatonia, psychosis/mania, ECT treatment

Acute onset of confusion, attention and cognition?

Delirium

What is the difference between delirium and dementia?

Delirium: Acute onset, fluctuating course, deficits in attention, psychomotor behavioral disturbances, reversible, functional

Dementia: Gradual onset, progressive course, deficits in memory, irreversible, structural

Delirium is the most common complication of what?

What percent of hospice and ICU patients experience delirium?

What percent of cases go unrecognized?

What is the one year mortality?

Post-operative

80%

70%

35-40%

What is acute onset attention issues which can have a fluctuating course?

Leading risk factor?

Etiology?

Delirium

Dementia (delirium worsens dementia course)

Vulnerability (dementia, illness/infection, age, depression, sensory impairment)

+ Insult (ICU, major surgery/anesthesia, sleep deprivation, metabolic derangement)

What are predisposing factors for delirium?

What are precipitating factors for delirium?

Cognitive issues, severe illness, depression, sensory issues, age

ICU, surgery, restraints, polypharmacy, sleep deprivation, catheterization, metabolic derangement

Hallmark of delirium?

Acute onset ATTENTION DEFICIT

Delirium has disturbances in what two regions of the brain?

What does EEG show that indicates cerebral dysfunction?

What does SPECT show?

What neurotransmitter abnormalities may be present?

Cortical, Subcortical

Symmetric slowing

Reduced cerebral bloodflow

ACh decrease, Dopamine increase

Acute onset of agitation, irritability, restlessness and hallucinations. What type of delirium is this?

Acute onset of inattention, cognitive slowing and lethargy. What type of delirium is this?

What symptom is common among both?

What is true of the clinical course?

Hyperactive

Hypoactive

Inattention

Fluctuating

What should we be looking for of on PE with delirium?

What exam must we perform?

What labs should we get?

What screening tool can we use?

Infection, hypoxia, dehydration *MEDICATIONS*

Neurological

CBC, CMP, albumin, UA, ABG +/- imaging (CXR, MRI)

CAM

What is the first line treatment for delirium?

REVERSE UNDERLYING CAUSE

Hydration

Ambulation

Socialization/Re-Orientation

Activities

Sleep schedule

Vision/Hearing aids

NO MEDS!!!!

T/F: Medications have been shown to prevent delirium or improve outcomes

FALSE

There are no medications that prevent delirium or improve outcomes

What must we eliminate in delirium patients?

What may be used to treat agitation but has no improvement with outcomes?

What may be used for seizures or alcohol withdrawal?

Restraints, indwelling catheters, excess medications

Haloperidol

Benzodiazepines

Most episodes of delirium resolve with what?

What percent of patients will have persistent symptoms?

Treatment of underlying cause

25%

Delirium worsens clinical outcomes and delays recovery of physical function