dementia and delirium

normal aging

• mild changes in memory and rate of information processing

• deficits are generally not very progressive and usually do not affect daily function

• learning or acquisition performance declined uniformly w/increasing age

• delayed recall or forgetting remained relative stable w/aging

dementia

disorder characterized by impairment of cognition typically involving memory and at least one other cognitive domain (language, visuospatial-connection/sequencing, executive function)

• must represent a decline from previous level of function and be severe enough to interfere w/daily function and independence

• 7th leading cause of death

dementia presentation

difficulty in

• retaining new information

• handling complex tasks

• reasoning

• spatial ability and orientation

• language

• behavior

dementia prevalence

• more than 55 mil have dementia worldwide

• every year there are nearly 10 mil new cases

• currently the seventh leading cause of death

• in the US, 1 in 3 seniors dies w/alzheimer’s or another dementia

dementia causes

neurodegenerative disease

• alzheimers disease

• dementia w/lewy bodies

• frontotemporal dementia

• parkinson disease dementia

• less common neurodegenerative disorders (ex: Huntingtons disease)

• non-neurodegenerative dementia (vascular dementia)

alzheimer’s pathology

accumulation of beta-amyloid plaques and neurofibrillary tangles distributed throughout the brain which degenerates neurons and synapses leading to atrophy of the cerebral cortex

dementia w/lewy bodies

produces a gradual, progressive decline in cognitive abilities w/motor parkinsonism

• rapid eye movement sleep behavior disorder

• visual hallucinations

• fluctuations in level of alertness

• prominent visuospatial dysfunction

• manifests parkinsonism and cognitive decline contemporaneously

frontotemporal dementia

damage to the frontal and temporal lobes of the brain

• symptoms include unusual behaviors

• emotional problems

• communication difficulties

• difficulty w/work

• difficulty walking

• occurs at a younger age (45-60)

parkinson disease dementia

• cognitive dysfunction dementia are common in parkinson disease

• cognitive impairment in parkinson disease exists on a continuum of severity to the extent it interferes w/daily activities

• visual hallucinations and delusions are a frequent manifestation

• dementia emerges five to eight yrs after the onset of movement disorder

huntington disease

inherited progressive neurodegenerative disorder characterized by choreiform movements, psychiatric problems, and dementia

• caused by a trinucleotide repeat in the huntingtin (HTT) gene and inherited in an autosomal dominant pattern

• pathophysiology still not fully understood

NO KNOWN CURE, treatment is symptomatic and remains supportive

risk factors for dementia and cognitive decline

• low educational attainment

• midlife hypertension

• midlife obesity

• hearing loss

• late life depression

• diabetes

• physical inactivity

• smoking

• social isolation

global deterioration scale for assessment of primary degenerative dementia

thinking

stage 1: no dementia, no cognitive decline: normal function, no memory loss, people w/no dementia are considered in stage 1

stage 2: very mild cognitive decline, no dementia: forgets names, familiar objects, symptoms not evident to loved ones or doctors; expected duration of stage unknown

stage 3: mild cognitive decline, no dementia: increased forgetfulness, slight difficulty concentrating, decreased work performance, gets lost more frequently, difficulty finding right words, loved ones begin to notice; average duration of this stage is btwn 2 and 7 yrs

stage 4: moderate cognitive decline, early stage dementia: difficulty concentrating, forgets recent events, cannot manage finances, cannot travel alone to new places, difficulty completing tasks, in denial about symptoms, socialization problems: withdraw from fam and friends, physician can detect cognitive problems; average duration is 2 yrs

stage 5: moderately severe cognitive decline, mid stage dementia: major memory deficiencies, need assistance w/ADLs, forgets details like address and phone #, doesnt know time or date, doesnt know where they are; average duration 1.5 years in this stage

stage 6: severe cognitive decline (middle dementia), mid stage: cannot carry out ADLs without help, forgets familys names, forgets recent events, forgets major events in past, difficulty counting from 10, incontinence, difficulty speaking, personality and emotional changes, delusions, compulsions, anxiety; average duration is 2.5 yrs

stage 7: very severe cognitive decline (late dementia), late stage: cannot speak or communicate, req help w/most activities, loss of motor skills, cannot walk, average duration of this stage is 1.5-2.5 yrs

functional assessment staging test

function

clinical dementia rating

thinking and function

goal for dementia treatment?

to preserve function and autonomy for as long as possible and to maintain quality of life for both patient AND caregivers

cholinesterase inhibitors

• main stay treatment for alzheimer disease

• does NOT prevent the progression to AD

• 40-50% pt show improvement

diet and dietary supplements for dementia

mediterranean diet (high in fruits, veggies, whole grains, nuts, seeds, fish, healthy oils) currently the most promising diet for brain health

antioxidant w/a plausible mech of action (evidence is inconsistent)

vitamin E/gingko biloba

vitamin B, coconut oil, fish oil

• better to eat antioxidants (fresh fruit and veg)

• and healthy fats (omega 3 fatty acids - salmon, flax seeds, walnuts

nursing care of people with dementia

appropriate use of medications

• cholinesterase inhibitors

• atypical antipsychotics and mood stabilizers (agitation and behavioral disturbances)

• antidepressants and anxiolytics for depression and anxiety

advanced dementia

• feed and nutrition (oral versus tube feed)

• infections and fever (resp and urinary tract)

interventions for communication challenges with dementia

stroke → stroke rehabilitation

finding the right word? → supply the word

don’t know what they mean? → ask them to describe it or point to it

lost in the middle of what they are saying? → repeat their first word, this may help them to get started again

trouble expressing an idea? → guess what they are trying to say and confirm

appear relaxed → create a calm environment

behavioral challenges in dementia

potential precipitators

• strange situations

• confusion

• groups of ppl

• noises

• being asked to do something they find difficult

• needing to think about several things at once

• being cared for by someone who is rushed or upset

• not wanting to appear inadequate

• not understanding what they saw or heard

• being tired/not feeling well

• not being able to express thoughts, etc

• being treated like a child

combativeness can often be prevented by being alert to the person’s stress level

care giver impact

• 30% caregivers are age 65 or older

• 2/3 are women, 1/3 daughters

• most caregivers (66%) live w/person w dementia

• 1 quarter third of dementia caregivers are “sandwich generation” caregivers → aging parent and at least one child

• devastating role on caregivers. compared w/caregivers of ppl w/o dementia 2x as many cg of those w/dementia indicate substantial emotional, financial, and physical difficulties

• of total lifetime cost of caring for someone w/dementia, 70% is borne by families either through out of pocket health and long term care expenses or from the value of unpaid care

interventions for behavior challenges with dementia

(for nursing and family)

if person w/dementia becoming upset w/something being done, STOP THE OFFENDING BEHAVIOR and allow time to rest

• adjusting environmental factors when possible

• addressing loneliness

• structured activities

• appropriate use of medication

the best way to manage behavioral disturbances in dementia depends on the severity of the symptoms

montreal cognitive assessment (MoCA)

most sensitive and validated cognitive screening tool used widely internationally (many languages/versions)

18-25= mild cognitive impairment

10-17= moderate cognitive impairment

less than 10= severe cognitive impairment

delirium

a clinical syndrome caused by a medical condition, substance intoxication or withdrawal or medication side effect that is characterized by disturbance of consciousness w/reduced ability to focus, sustain or shift attention

• disturbance in attention (dev over short period of time)

• an additional disturbance in cognition

• disturbances are not better explained by another preexisting, evolving, or established neurocognitive disorder

• disturbance is caused by a medical condition, substance intoxication, or withdrawal, or medication side effect

delirium presentation

• loss of mental clarity

• distractibility (patients flow of thought)

• may appear drowsy, lethargic, semicomatose - more advanced cases

OR

• hypervigilance seen more in cases of alc or sedative drug withdrawal

• change in cognition - memory loss, disorientation, difficulty w/language and speech

• hallucinations - visual, auditory, somatosensory

• language difficulties ex: lose ability to write or to speak a second language

evaluation for delirium

confusion assessment method - identifies and recognizes delirium quickly and accurately in both clinical and research settings

investigate medical causes

• fluid/electrolyte imbalances

• infections

• drugs or alcohol toxicity

• withdrawal from alcohol

• withdrawal from barbiturates, benzos, and selective serotonin reuptake inhibitors

• metabolic disorder (hypoglycemia, hypercalcemia, uremia, liver failure, thyrotoxicosis)

• low perfusion states (shock, HF)

• postop states especially in older adults (pain)

prevention and nursing care: delirium

SAFETY KEY!

orientation protocols - clock, calendar, windows, verbally reorienting pt

cognitive stimulation - provide activities such as regular visits dont overstimulate especially at night

sleep - avoid procedure during sleeping; reduce night time noise

early mobilization and minimal use of physical restraints

delirium (medical emergency)

causes: “I WATCH DEATH”

I: infections

W: withdrawal

A: acute metabolic

T: trauma

C: CNS disease

H: hypoxia

D: deficiencies

E: environmental

A: acute vascular

T: toxins/drugs

H: heavy metals (LEAD AND MERCURY)

alcohol withdrawal delirium

“delirium tremens or DTs”

rapid onset fluctuating disturbance of attention and cognition sometimes w/hallucinations in the presence of alcohol withdrawal

• withdrawal delirium typically begins within 72-96 hrs after pt last drink

in most severe manifestations its accompanied by agitation, severe tachycardia, hypertension, drenching sweats, and fever (extreme autonomic hyperactivity)

mod-sev withdrawal symptom of alcohol withdrawal include hallucination, seziures, or DTs - latter two can be life threatening!

communication interventions in persons w/delirium

• keep conversations basic and one topic at a time

• talk in calm soothing voice

• give time to respond

• remind where they are and what is happening

• avoid asking too many questions

• if having a hallucination, DO NOT ARGUE W/THEM OR TRY TO CORRECT THEM, INSTEAD ACKNOWLEDGE THEIR FEELINGS AND CALMLY REASSURE THEM

behavior interventions in persons w/delirium

• have someone stay in room w/patient

• have regular and night routine

• keep room calm and quiet

• make sure theyre comfortable

• well nourished and hydrated

• sensory items available

• re-orient!

delirium vs dementia

delirium

• rapid onset (hrs to day or two)

• ability to stay focused is impaired

• symptoms can come and go several times in a day

dementia

• onset of minor symptoms that progress over years

• remains alert in early stages

• memory and thinking skills stay at a constant level

communication challenges in dementia

expressing themselves

• difficulty in finding words

• difficulty remembering names of people or objects

• substitute words w/similar sounds (wrong for ring)

• substitute words w/related meaning (wedding for ring; music thing for piano)

• describe the object they cannot name

• difficulty communicating the whole thought, but can com words within the thought (bus-home for “im concern about missing the bus that takes me home” or rambling thoughts, use of curse words…