Dementia vs. Delirium

Comparison of Dementia and Delirium

Dementia Characteristics
- Classification: Chronic and permanent condition.
- Onset: Gradual onset.
- Progression: Declines over time.
- Common Examples:
  - Vascular dementia.
  - Alzheimer disease.
  - Parkinson disease.
- Clinical Goal: Focus on managing symptoms.
Delirium Characteristics
- Classification: Acute and reversible condition.
- Onset: Abrupt onset.
- Progression: Waxes and wanes (fluctuating levels of consciousness).
- Triggers: Tied to a specific physical or environmental trigger.
- Common Examples:
  - Hospitalization.
  - Infection.
Shared Symptoms (S/S Dementia & Delirium)
- Cognitive impairment.
- Confusion.
- Memory issues.
- Agitation.
- Disorientation.

Risk Reduction and Prevention Strategies

Dementia Risk Reduction
- Nutrition and Lifestyle: Good nutrition and regular exercise.
- Mental Health: Stress reduction activities.
- Cognitive Health: Stay engaged, remain active, and seek new challenges.
- Brain Protection:
  - Trauma prevention (Protect your brain!).
  - Vascular health management.
  - Alcohol use monitoring/limitation.
Delirium Risk Reduction
- Environment: Keep the patient oriented and maintain sleep-wake cycles (e.g., keep blinds open during the day!).
- Physiological Management: Limit periods of hypoxia and ensure good nutrition.
- Pharmacological Precautions: Avoid opioids and sedation whenever possible.
- Awareness: Stay engaged and informed.

The Montreal Cognitive Assessment (MOCA)

Overview
- Version: $7.1$ Original Version (by $Z. Nasreddine MD$ ).
- Total Possible Score: $30$ points.
- Education Adjustment: Add $1$ point if the subject has $\le 12$ years of education.
Assessment Components
- Visuospatial/Executive ( $5$ points total):
  - Alternating Trail Making ( $1 \rightarrow A \rightarrow 2 \rightarrow B$ , etc.).
  - Copying a cube ( $1$ point).
  - Clock Drawing: Must include Contour, Numbers, and Hands set to "Ten past eleven" ( $3$ points).
- Naming ( $3$ points total): Identification of animal illustrations (e.g., Lion, Rhinoceros, Camel).
- Memory:
  - Read a list of words: Face, Velvet, Church, Daisy, Red.
  - Two trials are performed even if the first is successful.
  - No points are awarded for these initial trials; points are only given for uncued delayed recall.
- Attention ( $6$ points total):
  - Forward digit span: Repeat $2, 1, 8, 5, 4$ .
  - Backward digit span: Repeat $7, 4, 2$ ( $1$ point).
  - Vigilance: Tap hand at each letter $A$ during a read list ( $F, B, A, C, M, N, A, A, J, K, L, B, A, F, A, K, D, E, A, A, A, J, A, M, O, F, A, A, B$ ). No points if errors $\ge 2$ .
  - Serial $7$ Subtraction: Start at $100$ . Sequence: $100, 93, 86, 79, 72, 65$ . (Scoring: $4-5$ correct = $3$ pts, $2-3$ correct = $2$ pts, $1$ correct = $1$ pt).
- Language ( $3$ points total):
  - Sentence repetition: "I only know that John is the one to help today" and "The cat always hid under the couch when dogs were in the room."
  - Verbal Fluency: Name the maximum number of words beginning with the letter $F$ in $1$ minute (Target is $\ge 11$ words).
- Abstraction ( $2$ points total): Determine similarities between word pairs (e.g., banana-orange = fruit; train-bicycle; watch-ruler).
- Delayed Recall ( $5$ points total): Recalling the word list (Face, Velvet, Church, Daisy, Red) after $5$ minutes. Points for uncued recall only. (Optional cues: Category or Multiple choice).
- Orientation ( $6$ points total): Date, Month, Year, Day, Place, City.
MOCA Scoring Thresholds
- Normal Cognitive Function: $\ge 26/30$
- Mild Cognitive Impairment: $18-25$
- Moderate Cognitive Impairment: $10-17$
- Severe Cognitive Impairment: $< 10$

Progression Stages of Dementia

Mild Dementia
- Short-term memory loss.
- Aware of issues; may attempt to hide memory loss.
- Slow decline in cognitive ability.
- Difficulty learning new things.
- Planning difficulties.
- Mood or personality changes; social withdrawal.
- Starts to require cues or assistance with Activities of Daily Living (ADLs).
Moderate Dementia
- Needs repeated instruction, even for simple tasks.
- Severe memory loss (may not recognize family members).
- Wandering behavior.
- Needs consistent cues and assistance with ADLs.
- Paranoia and outbursts.
- Often requires round-the-clock supervision.
Severe Dementia
- Unable to speak or ambulate.
- Severe difficulty swallowing.
- Significant weight loss.
- Risks as mobility and nutrition decline:
  - Pressure injuries.
  - Respiratory failure.
  - Contractures.
  - Pneumonia.

Management Approaches

Delirium Specific Management
- Reorient the patient.
- Provide reassurance.
- Explain all aspects of care.
Dementia Specific Management
- Do NOT correct the patient.
- Validate feelings.
- Use redirection.
Integrated Management (Used for Both)
- Maintain a calm approach.
- Involve the patient in care as much as possible.
- Individualized Care: Tailor the environment to established habits. Example: If a patient always exits the bed on the left side, the walker should be placed on the left side to ensure safety and comfort.

Pharmacological Interventions

Donepezil
- Class: Cholinergic.
- Onset: $3-4$ hours.
- Half-life: Exceptionally long ( $100+$ hours).
- Dosing Protocol: Requires slow increase in dosing.
- Side Effects: Nausea, vomiting, diarrhea ( $N/V/D$ ), insomnia, muscle cramps, fatigue, anorexia, and bradycardia.
Rivastigmine
- Class: Cholinergic.
- Administration: Available PO (oral) or TD (transdermal) patches.
- Clinical Note: Patches are specifically helpful for patients with severe dementia who may lose the ability to swallow or regularly refuse oral pills.
- Dosing Protocol: Slow dose increases.
- Side Effects: Nausea, vomiting ( $N/V$ ), muscle cramps, and sleep disturbance.
Memantine
- Class: NMDA-receptor antagonist.
- Dosing Protocol: Titration can be ramped up weekly rather than every $2$ weeks.
- Side Effects: Headache, dizziness, confusion, diarrhea or constipation, fatigue, hypertension, aggressive behavior, abdominal pain, and urinary incontinence.