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Dementia & Delirium
Prakash Babani
Psychiatry, PGY-3
Special Thanks . . .
Dr. T. Lau
Psychiatry Residency Program Director
Table of Contents
Delirium
• General Review
• Management
Table of Contents
Neurocognitive Disorders
•Alzheimer’s
•Vascular
•Frontotemporal
•Neurodenerative
– Lewy Body, Huntington’s, Parkinson’s
DELIRIUM
Case
• 68 year old woman who you, as her family
physician have followed over many years,
presents with increasing confusion, gait
instability, falls, and incontinence.
• The change appears abrupt.
• She is now sleeping much of the day and is up at
night.
Case
• She is on several medications including beta
blockers, diuretics and Mobicox for arthritis.
• She continues to have some brandy after supper.
• When she last came to the clinic you were away
and a locum prescribed some clonazepam to help
her sleep better and relieve some of her anxiety.
Case
• She is admitted to the hospital under your care.
– What is in your differential diagnosis?
– What tests would you order?
Case
• A urine C&S and CT head were normal.
• Routine blood work was also normal.
• She is now extremely agitated at night. Falling
frequently and is distressed with the belief that people
are trying to kill her and she has to escape out of this
prison. The nurses on the floor are requesting
sedation or restraints for safety.
– What are your next steps and why?
Delirium
• Disturbance of 4Cs
–C
Consciousness (focus, sustain or shift
attention)
–C
Cognition (memory, disorientation,
language) or perceptual disturbance
–C
Course
–C
Consequence of GMC
Delirium
• Why is it important?
– Delirium in the elderly patient is associated
with increased mortality, longer hospital stays,
and increased risk of institutional placement.
Delirium
• DSM-5 Subcategories:
– due to GMC, substance
intoxication/withdrawal, multiple etiologies
• Prevalence: 10-15% of those hospitalized.
• Under recognized in those >65 higher (10-40%).
• Independent risk factor for mortality:
– 40% @ one yr.
• Lab features: EEG generalized slowing
Delirium
Meagher (1996), BJP
Hypoactive:
• Decreased Ach in nucleus basilis & RAS, associated
with CVA, metabolic disorders, late sepsis,
aspiration, pulmonary embolism, decubitus ulcers and
other complications related to immobility.
• Characterized by: Unawareness, inattention,
decreased alertness, sparse or slow speech, lethargy,
decreased motor activity, staring, apathy. Liptzin
(1992) BJP
Delirium
Meagher (1996), BJP
Hyperactive:
• Mediated by LC-NA.
• Withdrawal states, acute infection,
• Risk factors
– Medical illness, sensory impairment, hx of
delirium, ETOH, pre-existing brain damage (eg.
Dementia), malnutrition
INDEPENDENT PRECIPITATING FACTORS
(n=196)
Precipitating factor
Use of physical restraints
Malnutrition
>3 medications added
Use of bladder catheter
Adjusted RR
4.4 (2.5-7.9)
4.0 (2.2-7.4)
2.9 (1.6-5.4)
2.4 (1.2-4.7)
• How do we treat Delirium?
Delirium: Treatment
Biological
•Determine cause if possible and treat (eg. infection,
med ASE’s, metabolic d/o, pain, renal/hepatic failure,
drug intoxication/withdrawal, SOL, CVA, NPH, etc).
•Manage sx (low dose neuroleptics), watch for AC
ASE of meds (Breitbart AJP 1996).
Delirium: Treatment
Psychological
• Establish calm and safe environment. Develop trust
and provide reassurance
• Place near NS station with adequate lighting,
reorientation, familiar faces, voices.
Social
• Support family, may be helpful in decreasing
distress and reorientation
Delirium
Environmental interventions
•
•
•
•
•
Noise reduction
Diurnal variation in noise and lighting
Frequent reorientation
Day/date in room, big clock in room
Keep familiar items in room e.g., family
pictures
• Early mobilization, physical therapy
• Limit use of restraints
• Early recognition and treatment of dehydration
MCQ
The following is true of delirium
a) In the elderly, it is rare and most often completely
reversible
b) Hyperactive subtypes are more often missed
c) It is a significant independent risk factor for death
d) It can be superimposed on dementia or depression
e) It is better to use benzodiazepines than
neuroleptics for psychotic and behavioural
symptoms
C
NEUROCOGNITIVE
DISORDERS
Case
• A 78-year-old widow who lives alone and whom
you have seen infrequently is brought to your
office by her daughter.
• Although the patient has no complaints, her
daughter indicates that for the past 2 years she has
become more forgetful. Her behaviour is
repetitive, and she sometimes calls her daughter
several times a day to ask the same question.
Case
• The quality of her housework is beginning to
decline (her house is untidy, food is left to spoil in
the refrigerator, she is limiting food preparation to
simple, familiar items, and she has to check
recipes even for easy dishes).
• Her personal hygiene is also declining, and some
bills are not being paid on time.
Case
• What is in your differential diagnosis?
• What tests would you order?
• What are your next steps?
Case
• You see her several years later in a nursing home.
She is more confused and no longer recognizes
you.
• She is frequently exit seeking and is resistive with
care at times. She has injured staff and co
residents during periods of anger and agitation.
• What would you do?
Neurocognitive Disorders
• What is a Neurocognitive Disorder?
1. Cognitive decline in ONE domain that…
2. Effects ADL’s and…
3. Patient is not delirious and…
4. It isn’t another mental disorder.
DSM-5 Criteria
Neurocognitive Disorders
1. Cognitive decline in ONE domain is determined
based on:
Concern about decline in cognitive function
AND
Impairment on Cognitive performance testing
Neurocognitive Disorders
2. Effects ADL’s
Does it interfere with independence?
Yes
Major NCD
No
Mild NCD
Neurocognitive Disorders
3. Patient is not delirious
3. It’s not another mental disorder
- MDD
- Schizophrenia
- Etc.
Neurocognitive Disorders
Types
•
•
•
•
Alzheimer’s
Vascular
Lewy Bodies
Frontotemporal
• Others
– Parkinson’s
– Huntington’s
– Prion
– HIV
– Substance/Meds
No. of cases (x1000)
800
600
Dementia
AD
VaD
400
200
0
1991
2001
2011
2021
2031
Canadian Study of Heath and Aging Working Group. CMAJ 1994;150:899913.
Neurocognitive Disorders
Types
Alzheimer’s
•Insidious onset, gradual progression
•Memory, language, and visuo-spatial defects
•Indifference, delusions
•Normal B/W
Progression of Alzheimer’s
Mild cognitive
impairment
Memory
impairment
No ADL
deficits
Apathy,
anxiety,
irritability
Mild - MMSE >20
• Forgetfulness
• Problems with shopping, driving and hobbies
• Depression
Nursing home
placement
Moderate - MMSE 10-20
AD memory
Progression
• Marked
loss
• Require help with ADLs
• Wandering
• Insomnia
• Delusions
Death from
pneumonia
and/or other
comorbidities
Severe - MMSE <10
• Very limited language
• Loss of basic ADLs
• Incontinence
• Agitation
Adapted from Galasko D. Eur J Neurol. 1998;5:S9-S17.
Therapeutic Strategies
Detection
Latency
.Traumatisms
. Vascular risk factors
Symptoms
Induction
.Genetic/hereditary
Pathogenesis
Disease
Primary
Prevention
Vaccine
Estrogen
NSAID
Ginkgo
Secondary
Prevention
(“Mild cognitive
Impairment”)
Antioxydants
Anti-inflammatories
Neurotrophic factors
Estrogens
Vascular Prevention
Symptomatic
Treatment
Cholinergic replacement
Therapy
Glutamate Modulation
Mood and Behaviour
Management
PIECES
P
• Physical: DELIRIUM, diseases, drugs,
discomfort, disability
• Intellectual: dementia – cognitive
abilities/losses
• Emotional: depression, psychosis
• Capabilities:environment not too demanding yet
stimulating enough, balancing demands and
capabilities
• Environment: noise, relocation, schedules…
• Social, cultural, spiritual: life story,
relationships family dynamics, personality
traits……
S
I
E
E
C
Pharmacologic Management of BPSD
 Herrmann and Lanctot
Canadian Journal of Psychiatry Oct 2007
 Atypicals
 Remain the best studied and most effective but side
effects limit their use
 Antidepressants
 Some evidence for Trazadone and Celexa but effect size
may limit use in urgent situations
Pharmacologic Management of BPSD
 Herrmann and Lanctot
Canadian Journal of Psychiatry Oct 2007
 Anticonvulsants
 Tegretol can be effective but poorly tolerated. Negative
studies with Epival. Not as thoroughly studied as
atypicals
 Benzodiazepines
 Short term use only
MCQ
The following is true of Alzheimer’s
a) Motor symptoms are present early in the disease
b) There is usually a step wise decline
c) The ‘head turning sign’ refers to sexual
disinhibition
d) Behavioural symptoms are often the most
distressing symptom for families and caregivers
e) Vascular events may co-occur but play no role in
the pathophysiology
D
Case
• 82 year old married man who you have followed over
several years having treated him for hypertension, diabetes
and peripheral vascular disease.
• He has a history of paroxysmal atrial fibrillation and is on
Coumadin. He has not been as steady while walking lately
and had some recent falls. His wife and family have
become increasingly concerned that something is wrong.
• He is forgetful and needs constant reminders even to change
and get dressed.
• The family have also observed that he seems very emotional
at times. He has been getting lost while driving.
Vascular Dementia
Memory problems +
Executive dysfxn
Vascular evidence
Clinical features:
– Cognitive changes: executive dysfxn with few
language impairments, often motor, gait
abnormalities. Memory problems often retrieval
related: working memory.
Vascular Dementia
• Neurological:
Dizziness, focal motor, pseudobulbar palsy
• Risk Factors:
M, age, apo E4, race=black / asian, HTN, CAD,
DM, Hyperchol, smoking
MCQ
Which of the following is true regarding Vascular Dementia
a) Lateralizing findings are common
b) Gait changes are uncommon
c) Gradually progressive decline is typical
d) Neuroimaging or clinical evidence of CVA is necessary
for the diagnosis
e) Retrieval < encoding deficits on neuropsych testing
D
Case
•
60 year old married mother of 2 who
presents with a 2 year history of
increasingly strange and
uncharacteristic behaviour.
•
She was caught shoplifting and has
become surprisingly disinhibited. Her
awareness of her social
inappropriateness was negligible and
quite embarassing for her family who
feel she seems like a different person.
Case
•
Her language also has changed where she has
experienced increasing difficulties speaking
clearly. She often mutters and has been persisting
in rigid patterns of behaviour, for instance,
ruminating over a routine of watching TV and
eating.
Case
QUESTIONS
1. What is your differential?
2. What differentiates FTD from AD?
3. Are there any differences in treating this condition?
MCQ
Frontotemporal Dementia is characterized by
a) Memory and visual spatial impairment early on
b) Personality changes later with disinhibition
c) Early loss of insight, decline in social interpersonal
conduct with impaired regulation, emotional
blunting, executive skills deficits, frontal signs
d) Characteristic functional neuroimages with occipital
cerebral hypometabolism
e) Low rates of family history
C
Case
• 65 year old woman who presents with a two year
history of strange behaviour and sleeping
problems and one year history of resting tremor,
falls and increasing mental and physical slowness.
• As her family physician you diagnosed
Parkinson’s disease and initiated L-Dopa. The LDopa helped with her motor symptoms.
Case
• Periods of confusion became evident as were well
formed visual hallucinations. Because of your
suspicion of delirium and some urinary symptoms
you treated her for a UTI.
• Despite this, the fluctuations and hallucinations
continue. Her daughter who is the primary
caregiver feels she is at her wits end and is asking
you what to do.
Case
QUESTIONS
1. What is your differential?
2. What is the difference between DLB
and PDD?
Lewy Body Dementia
McKeith Neurology 96 updated 2006
Diagnosis
•Dementia
•Plus >2/3 (probable, 1/3 possible)
– Fluctuating cognition
– VH’s well formed + delusions
– Parkinsonism
•Pathologically
– identified with Ubiquitin Stain. LB seen in PD in
SN. a-synnuclein stain better ie. No NFT staining
Lewy Body Dementia
McKeith Neurology 96 updated 2006
LBD and Delirium
•Fluctuating LOC/attention. LBD has attn to do
months in reverse
Parkinson’s and DLB
•wrt to PD hallucinations and depression but not
delusions suggesting cortical pathology for delusions.
•Louis’97 reported rest tremor lower in DLB but
myoclonus higher.
Lewy Body Dementia
McKeith Neurology 96 updated 2006
Clinical Features
– Repeated falls
– Syncope w transient LOC
– Neuroleptic sensitivity
– Systematized delusions (>50%)
– Hallucinations in other modalities
– Increased rates of depression (40-50%)
– Misidentification syndrome v. common
Lewy Body Dementia
McKeith Neurology 96 updated 2006
Treatment
– Seems to respond well to AchEI
– Extreme caution with neuroleptics
MCQ
Which of the following is true regarding Dementia
with Lewy Bodies
a) It is rare
b) It is associated with severe neuroleptic sensitivity,
REM sleep disorders, and falls
c) PET/SPECT shows increased Dopamine uptake
in the basal ganglia
d) Can occur in patients who have had the motor
symptoms of Parkinson’s for over one year
e) Response to AchEI’s is poor
B
Differentiating them...
AD
• insidious onset, gradual
progression
• memory, language, and
visuospatial defects
• indifference, delusions
• Normal B/W
Subcortical Vascular
•
•
•
•
•
DLB
• visual hallucinations
• fluctuating course
• Parkinsonism
Frontotemporal
Degeneration
 Personality changes early,
disinhibition
CVS risk factors, step wise decline
Gait changes, EP signs
 Executive skills deficits, frontal signs,
preserved visuospatial early on
Recall, executive skills deficits
Depression, apathy
 Characteristic functional neuroimages
MRI subcortical lacunes or
hyperintensities
Lau, T. Canadian Journal of Diagnosis Nov/Dec 2009
QUESTIONS
You can contact me at [email protected]
if you have any further questions or concerns.