Delirium and Dementia Notes

Delirium vs. Dementia

Delirium

• Reversibility: Delirium can be reversed by addressing underlying issues, unlike dementia, which is a progressive and irreversible cognitive decline.
• Symptom Characteristics:
  • Disturbances of consciousness:
  • Fluctuations in awareness and attention.
  • Changes in cognition:
  • Memory deficits, disorientation, and language disturbances.

Development and Etiology

• Rapid Onset: Delirium has a rapid onset, typically occurring over hours to days.
• Etiology:
  • Identifiable physiological, metabolic, or cerebral disturbances or diseases:
  • Examples include infections, electrolyte imbalances, and organ failure.
  • Drug intoxication or withdrawal:
  • Alcohol withdrawal: Delirium tremens.

Key information

• Boxes 24.1 and 24.2 in the book are important:

  • 24.1: Comparison of delirium and dementia:
  • Key differences in onset, progression, and reversibility.
  • 24.2: Drugs causing delirium:
  • Anticholinergics, benzodiazepines, and opioids.

• Importance of Accurate Medication Lists:

  • Nurses often identify medication-related issues:
  • Drug interactions and adverse effects.
  • Obtain lists from patients, relatives, or pharmacies:
  • Comprehensive medication reconciliation is crucial.

Risk Factors

• Increased severity of physical illness:
  • The more severe the illness, the higher the risk.
• Older age:
  • Age-related physiological changes increase vulnerability.
• Hearing impairment:
  • Sensory deprivation can contribute to delirium.
• Decreased food or fluid intake:
  • Dehydration and malnutrition exacerbate delirium.
• Medications:
  • Polypharmacy increases the risk of drug-induced delirium.

Delirium in Children

• Can occur with high fevers or when very tired:
  • Especially in young children.
• Example: Fever of $107.7^{\circ}F$ leading to non-recognition until helicopter transport:
  • Extreme hyperpyrexia can cause delirium.
• Anticholinergics can also cause effects in children:
  • Increased heart rate, dry mouth, blurred vision, constipation, urinary retention, hallucinations, cognitive problems, delirium, and convulsions.

Treatment and Prognosis

• Transient condition that clears with treatment of the underlying cause:
  • Resolving the underlying medical issue is key.
• Psychopharmacological treatment:
  • Sedation to prevent injury:
  • Use of medications to calm and protect the patient.
  • Antipsychotics (e.g., Haldol) to decrease agitation and psychotic symptoms:
  • Careful monitoring to avoid side effects.
• Other medical treatments:
  • Increasing fluid intake:
  • Addressing dehydration.
  • Caution with benzodiazepines (benzos) in the elderly as they can worsen delirium, but useful in alcohol withdrawal:
  • Use judiciously and monitor closely.

Assessment

• Medical history: Relevant medical conditions.

• Medication list: Current medications and potential interactions.

• Alcohol use: History of alcohol consumption and withdrawal risk.

• General appearance and motor behavior:

  • Disturbed psychomotor behavior (hyperactive or hypoactive):
  • Restlessness, agitation, or slowed movements.
  • Speech problems (slurred or rambling):
  • Dysarthria or incoherent speech.

• Mood and affect:

  • Rapid, unpredictable mood shifts:
  • Emotional lability.

• Thought process and content:

  • Disorganized, fragmented thoughts:
  • Difficulty with coherent thinking.
  • Inability to sustain attention:
  • Easy distractibility.

• Sensorium and intellectual processes:

  • Decreased awareness of environment:
  • Reduced responsiveness.
  • Disorientation to place:
  • Confusion about location.
  • Easy distractibility:
  • Difficulty focusing.

• Impaired judgment and insight:

  • Poor decision-making and lack of awareness.

• Self-concept:

  • Fearfulness:
  • Anxiety and apprehension.
  • Feeling threatened:
  • Paranoia.

• Roles and relationships:

  • Ability to fulfill roles:
  • Impact on social functioning.

• Physiological and self-care:

  • Sleep patterns:
  • Disrupted sleep-wake cycle.
  • Eating habits:
  • Poor appetite and nutritional intake.
  • Perception of internal body cues:
  • Difficulty interpreting bodily sensations.

Goals and Interventions

• Goals:
  • Free from injury: Ensuring patient safety.
  • Increased orientation and reality: Improving awareness.
  • Balance of activity and rest: Regulating activity levels.
  • Adequate nutrition and fluid balance: Maintaining hydration and nutrition.
  • Return to optimal functioning: Restoring baseline cognitive function.
• Interventions:
  • Promoting client safety: Environmental modifications, supervision.
  • Managing confusion:
  • Orientation: Providing frequent reminders of time, place, and person.
  • Low clear voice: Speaking calmly and simply.
  • Touch if appropriate: Providing reassurance through physical contact.
  • Avoid sensory overload: Reducing environmental stimuli.
  • Promoting sleep and proper nutrition:
  • Avoiding daytime naps: Encouraging nighttime sleep.
  • Ensuring safety through vision: Corrective lenses if needed.
  • Allowing client to make decisions: Promoting autonomy.
  • Minimizing noise: Creating a quiet environment.
  • Home help, rehabilitation, adult day care, residential care, support groups: Providing comprehensive support.

Key points about Delirium discussed further

• Onset, Course, Duration, Consciousness, Attention, Memory, Self-Motor Changes, and Sleep-Wake Cycle.
• Delirium is rapid onset, fluctuating, and potentially reversible in days to weeks.
• Consciousness is altered, with significant inattention and impaired immediate recall.
• Conditions causing delirium: urinary tract infection (UTI) (especially in older women), hypoxemia (e.g., in COPD patients), thiamine deficiency (alcoholics), cardiovascular shock, brain tumors, sleep deprivation, renal or hepatic failure, hypoglycemia, infections (UTIs, neurotrauma, HIV, syphilis, pneumonia, meningitis, encephalitis), withdrawal.
• Treatment focused on addressing underlying cause, caution with benzos in elderly patients, use short-acting benzos if needed, consider client's history of falls.
• May exhibit restlessness, hyperactivity, or hypoactivity, prioritize safety. In these patients, break down tasks step by step, limit choices, use short simple sentences, provide orientation, note changes in orientation, offer one-on-one attention, ensure well-lit environment at night.
• Therapeutic touch, get consent first.

Dementia

• Progressive cognitive impairment with multiple cognitive deficits.
• Initially affects memory, followed by aphasia, apraxia, agnosia, and disturbance in executive functioning.
  • Aphasia: Deterioration in language.
  • Apraxia: Impaired motor function despite intact motor abilities.
  • Agnosia: Inability to recognize or name objects.
  • Disturbance in executive functioning: Inability to think abstractly, plan, initiate, or stop complex behavior.
• Memory impairment is an early sign.

Stages of Dementia

• Mild Dementia:
  • Forgetfulness
  • Difficulty finding words
  • Losing objects
  • Anxiety about losses
• Moderate Dementia:
  • Confusion, progressive memory loss
  • Inability to perform complex tasks
  • Orientation to person and place but requiring assistance
• Severe Dementia:
  • Personality and emotional changes
  • Delusions
  • Wondering at night
  • Forgetting family names
  • Need for assistance with all activities

Etiology

• Decreased metabolic activity noted postmortem.
• Genetic component (e.g., Huntington's disease).

Types of Dementia

• Alzheimer's Disease:
  • Gradual onset, loss of function.
  • May be genetic.
• Lewy Body Dementia:
  • Neuropsychic and motor signs and symptoms.
  • Delusions and visual hallucinations.
• Vascular Dementia:
  • Sudden onset after vascular lesion in the cortex.
  • Decreased blood flow to the brain.
• Frontotemporal Lobar Degeneration (Pick's Disease):
  • Degenerative brain disease affecting frontal or temporal lobes.
  • Personality changes, decreased social skills.
• Prion Diseases (Creutzfeldt-Jakob Disease, Mad Cow Disease):
  • Infectious causes.
  • Altered vision, loss of coordination, abnormal movements.
• Dementia Related to Human Immunodeficiency Virus (HIV):
  • Varied signs and symptoms, mild to severe.
• Parkinson's Disease:
  • Slowly progressing tremor, rigidity, bradykinesia, postural instability.
• Huntington's Disease:
  • Inherited cerebral atrophy, demyelination, enlarged brain ventricle.

Assessment (the Mini-Mental State Examination (MMSE))

*Start through from a care planner by asking questions, and then asking them to actually do things, such as: What year season, date, kind of thing.* Start with simple assessment such as giving them instructions as far as examination.

• History:
  • Client may be unable to provide accurate history, necessitating contacting family or reviewing medical records.
• General appearance and motor behavior:
  • Aphasia, apraxia, uninhibited.
  • Confabulation (making up answers to fill memory gaps).
• Judgment and insight:
  • Poor judgment, unrealistic thinking about abilities.
• Self-concept:
  • Sadness, loss of self-awareness.
• Roles and relationships:
  • Profoundly affected.
• Physiological:
  • Disturbed sleep, incontinence, hygiene deficits.

Goals and Interventions

• Goals:
  • Freedom from injury, safety.
  • Involvement in surroundings.
  • Interaction with others.
• Interventions:
  • Promoting client safety through reassurance, door alarms, and monitoring visitors.
  • Promoting adequate sleep, nutrition, hygiene, activity, and involvement.

Role of Caregiver

• Often adult daughters or wives.
• Education about dementia and the disease process is crucial.
• Explain the disease process and address feelings of frustration.
• Need for help and respite.