Download Dementia vs Delirium

Dementia (Alziehmer’s) and Delirium
by John Burton, M.D.
Introduction
Dementia is a progressive decline in memory and at least one other cognitive
area in an alert person. These cognitive areas include attention, orientation, judgment, abstract
thinking and personality. Dementia is rare in under 50 years of age and the incidence increases
with age; 8% in >65 and 30% in >85 years of age.
Causes and Risk Factors
There are several risk factors for dementia:
•
•
•
•
•
•
Age
Down’s Syndrome
Head injury
Fewer years of education
Female
Genetics
* Early onset of mutations in chromosome 1, 14, and 21
* Late onset of mutations in
chromosome 19
-apolipoprotein E gen (APOE 2, 3, and 4)
4/4 greatest risk (3% of
population)
3/4 next risk (20% of population)
2 may be protective
APOE 4 neither
necessary nor sufficient to cause dementia
* Genetic screening is not recommended
Dementia results from brain damage. The causes include the following; Alzheimer’s Disease,
Stroke, Pick’s disease, Huntington’s, Downs Syndrome, Creutzfeldt-Jacob, AIDS, alcoholism,
Parkinson’s disease and other neurodegenerations.
Diagnosis
There are three purposes why diagnosing dementia is essential.
1. By determining the probable cause, treatable disorders can be identified, such as medication
toxicity (benzos, H2 blockers and anticholinergics), and thyroid disease.
2. There are symptoms and comorbidities that are treatable, such as depression, delirium (see
below), delusions, hallucinations, and agitation.
3. Caregivers must be identified and environmental issues taken into consideration.
A diagnosis of dementia is based on:
memory loss - both in short and long-term, plus one or more
of the following:
•
•
•
•
aphasia – language problems
apraxia – organizational problems
agnosia – unable to recognize objects or tell their purpose
disturbed executive function – personality and inhibition
Assessment
An assessment for dementia may include the following:
• History, both from the patient and close observers
• Focused physical
• Mini Mental State Exam
• Lab work including CBC, basic metabolic profile, TSH, Vitamin B12, STS
• If brain injury or space occupying lesion such as a tumor is in question, CT, or MRI.
PET scans are occassionally recommended in the early diagnosis of dementia although there
remains some controversy as to precisely their indication and value
Additionally, depression, delirium (discussed below), agitation, hallucinations, and delusions are
important comorbidities that must be taken into consideration. Behavorial issues may require a
referral to a specialist.
Treatment
There are both pharmacologic and non-pharmacologic interventions that may be beneficial for
patients with dementia.
Non-pharmacologic Interventions
• Social activities
• Adequate sleep
• Adherence to a strict schedule
• Maintenance of a proper stimulation level
• Adequate hydration
• Reformatting task (occupation therapy)
• Support caregivers
Pharmacologic Interventions (course is typically 10 years, but 2-20 possible)
• Prevention
* Vitamin E, and cognitive stimulation such as education
• Memory/attention
• Acetylcholinesterase Inhibitors
* Tacrine
* Donepezil hydrochloride
* Rivastigmine
tartrate
* Galantamine hydrochloride
• NMDA antagonists
* Memantine
* Others (Ginkgo biloba, caffeine, nicotine,
methylphenidate, NSAIDs)
• Behavioral * Antipsychotics
* Antidepressants
* Mood stabililizers
Dementia vs Delirium
In order to make a diagnosis of dementia, delirium must be ruled
out. However, patients with dementia are at increased risk of delirium and may have
both. Delirium is an acute disorder of attention and global cognition (memory and perception) and
is treatable. The diagnosis is missed in more than 50% of cases. The risk factors for delirium
include age, pre-existing brain disease, and medications. There are many causes, the most
common are:
D Dementia
E Electrolyte disorders
L Lung, liver, heart, kidney, brain
I
Infection
R Rx Drugs
I
Injury, Pain, Stress
U Unfamiliar enviroment
M Metobolic
Prevention of delirium includes the avoidance of psychoactive drugs, quiet environment, daytime
activity, dark and quiet at night, visual and hearing assistive devices, orientation devices, and
avoidance of restraints.
Diagnosis of delirium is based on clinical observation; no diagnostic tests are available. The
essential features of delirium include:
• Acute onset (hours/days) and a fluctuating course
• Inattention or distraction
• Disorganized thinking or a altered level of consciousness
Treatment of delirium, like dementia, is managed both pharmacologically and nonpharmacologically.
Non-pharmacologic management
• Optimize environment
• Personal belonging – photographs
• Quiet
• Sitter
Pharmacologic management
• Neuroleptics may be needed if the patient is having distressing hallucinations/delusions or the
patient is very agitated
• High potency with low anticholinergic activity
• Low dose
• Haloperidol or risperdone
• Benzodiazepine if delirium is secondary to benzo or alcohol withdrawal
What's the Difference Between Delirium
and Dementia?
By Esther Heerema, MSW
Updated December 14, 2012
Onset
Dementia: Dementia typically begins slowly and is gradually noticed
over time. If the person who's being evaluated is unknown to you,
getting a report of his usual functioning is key.
Delirium: Delirium is usually a sudden change in a condition. One
day, your loved one is doing fine, and the next, she may be very
confused and unable to get dressed. Delirium is also known as acute
confusional state, with the key being that it is acute, or sudden.
Cause
Dementia: The cause of dementia is typically a disease such as
Alzheimer's, vascular dementia, lewy body dementia, frontotemporal
dementia or a related disorder.
Delirium: Delirium is usually triggered by a specific illness, such as a
urinary tract infection, pneumonia, dehydration, illicit drug use, or
withdrawal from drugs or alcohol. Medications that interact with each
other can also cause delirium, so make sure your physician knows all
of the medications, supplements and vitamins you're taking, even if
they're natural substances.
Duration
Dementia: Dementia is generally a chronic, progressive disease that
is incurable. (There are some reversible causes of dementia such as
vitamin B12 deficiency, normal pressure hydrocephalus, and thyroid
dysfunction.)
Delirium: Delirium can last for a couple of days to even a couple of
months. Delirium is almost always temporary if the cause is identified
and treated.
Communication Abilities
Dementia: People with dementia may have difficulty finding the right
words, and the ability to express themselves gradually deteriorates as
the disease progresses.
Delirium: Delirium may significantly and uncharacteristically impair
someone's ability to speak coherently or appropriately.
Attention Span and Memory
Dementia: A person's level of alertness is typically not affected until
the late stages of Alzheimer's, whereas memory is significantly
affected throughout the disease.
Delirium: In delirium, the opposite is true. Memory functioning is
usually less affected in delirium but the ability to focus and maintain
attention to something or someone is very poor.
Activity Level
Dementia: Dementia tends to not affect a person's activity level until
the later stages.
Delirium: People with delirium are often either overly active (hyper
and restless) or under-active (lethargic and less responsive) compared
to usual functioning.
Treatment
Dementia: There are currently five medications approved by the FDA
to treat Alzheimer's disease, the most common type of dementia.
Those medications don't cure dementia, but sometimes can slow the
progression of the symptoms, including memory loss, poor judgment,
behavioral changes and more.
Delirium: Delirium requires immediate treatment by a physician.
Since it's usually caused by a physical illness or infection, medications
such as antibiotics often resolve the delirium.
Delirium in People with Dementia
Distinguishing between delirium or dementia is important; however, a
more difficult task may be identifying delirium in someone who already
has dementia. According to a study by Fick and Mion, approximately
22% of older adults in the community with dementia develop delirium.
However, that rate skyrockets to 89% for those who have dementia
and are hospitalized.
Knowing how to identify delirium in someone who is already confused
is critical for appropriate treatment and a faster recovery. Delirium
superimposed on someone with dementia also is connected with a
more than double mortality risk compared to those with delirium or
dementia alone.
So, how can you identify Delirium in Dementia? Here are 7
signs to look for:
4.
5.
6.
7.
8.
9.
10.
Increased agitation
Unusually resistive to care
Falls
Catastrophic reactions
Decreased communication
Inattention
Fluctuating alertness
(drugs are not tested, but I thought you
might be interested in knowing)
Treatment of Alzheimer's Disease
Medications and Non-Drug Approaches Used to Treat
Alzheimer's Disease
By Esther Heerema, MSW
Updated November 06, 2013
Drug Therapy for Cognitive Symptoms
Cognitive enhancers are medications that attempt to slow the
progression of Alzheimer's symptoms. While these medications appear
to improve thought processes for some people, the effectiveness
overall varies greatly. Cognitive enhancers need to be monitored
regularly for side effects and interaction with other medications.
Two classes of medication have been approved by the US Food and
Drug Administration for treatment of the cognitive symptoms of
Alzheimer's. They include Cholinesterase Inhibitors and N-Methyl DAspartate (NMDA) Antagonists.
Class 1: Cholinesterase Inhibitors
Cholinesterase Inhibitors act by increasing the levels of acetylcholine
in the brain. Acetylcholine is a chemical that facilitates nerve cell
communication in the areas of memory, judgment and other thought
processes. Researchers have found lower levels of acetylcholine in the
brains of individuals with Alzheimer's. There are four Cholinesterase
Inhibitor medications:
11. Aricept (donepezil): Approved for mild, moderate and severe
Alzheimer's
12. Cognex (tacrine): Approved for mild to moderate Alzheimer's;
however, Cognex is not marketed anymore by its manufacturer
because it has some significant side effects.
13. Exelon (revastigmine): Approved for mild to moderate
Alzheimer's
14. Razadyne (galantamine): Approved for mild to moderate
Alzheimer's
Class 2: N-Methyl D-Aspartate (NMDA) Antagonists
Namenda (memantine) is the only drug in this class and is approved
for moderate to severe Alzheimer's. Namenda appears to work by
regulating glutamate levels in the brain. Normal levels of glutamate
facilitate learning but too much glutatmate causes brain cells to die.
Namenda has been somewhat effective in delaying the progression of
symptoms in later Alzheimer's disease.
Drug Therapy for Behavioral and Emotional Symptoms
Psychotropic medications are used at times to treat the behavioral and
emotional symptoms of Alzheimer's disease. Psychotropics address the
psychological and emotional aspects of brain functioning.
These drugs can be effective but can also potentially cause severe side
effects. This class of medications is typically used after attempting
non-drug therapy and finding it to be inadequate.
Psychotropic medications include antidepressants, antipsychotics and
anti-anxiety medications, as well as mood stabilizers and hypnotic
medications. These medications are prescribed to address symptoms
such as depression, anxiety, insomnia, hallucinations and paranoia.
Non-Drug Approaches
Non-drug approaches focus on treating the behavioral and emotional
symptoms of Alzheimer's by changing the way we understand and
interact with the person with Alzheimer's, These approaches recognize
that behavior is often a way of communicating for those with
Alzheimer's. The goal of non-drug approaches is to understand the
meaning of the challenging behaviors and why they are present.
Non-drug approaches should generally be attempted before using
psychotropic medications since they do not have the potential for side
effects or medication interactions.
• Behavior Assessment
Identify a particular behavior and note
what seems to trigger the behavior. For example, if a shower
always makes your loved one agitated, try a bath instead. Or,
attempt to offer a shower at a different time of day. Rather than
using medication if someone is upset or agitated, a non-drug
approach tries to understand why they might be agitated.
Perhaps they need to use the bathroom, are in pain or think they
lost something. Note what precedes the behavior, try something
different and track the results.
• Know What to Expect
The old saying "Knowledge is power" is
very true here. Knowing what to expect can help you understand
behavior and recognize its source as the disease rather than the
person.
• See Things His Way
You can often avoid escalating troubling
behaviors by changing your own perspective. For example, if
your loved one is asking to see his mother (who may have been
deceased for many years), ask him to tell you about her, rather
than forcing him to confront the death of his mother. This is
called Validation Therapy, and it can be very effective in calming
the person who is upset.