Dementia Vs Delirium

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Dementia vs Delirium/Psychosis Presented
byVanessa Thompson, APRN-GNP-PMHNP-BCDirector
Behavioral Health Service Spartanburg Medical
Center
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Objectives
  Clinical Presentation of Dementia Clinical Hallmarks of Delirium  
  Statistics on Delirium and Dementia in the Elderly
  Diagnostic work up for Delirium and Dementia Medication Treatment for Both Nursing Interventions        
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• Clinical Presentation
• 82 year old female is seen in your office today
• Daughter reports her mother has not slept for the
  past 3 nights
• She has started looking for her deceased husband
  the past few days
• She was seen in the ED and started on an
  antibiotic for UTI and Norco for hip pain after a
  fall 5 days ago
• Lab review Urine C S gt100,00 colony count
• WBC-8.9, Hgb 10.5, Na134, K4.0, BUN, 0.9,
  TSH-5.99 B12-351 other labs WNL
• Meds Norco-5, Cipro 500 mg po bid x 10 days,
  ASA 81 mg qd, vitamin b12-1000 mcg qd, Lisinopril
  5 mg PO qd, Lopressor 12.5 mg po BID, Lexapro 5
  mg po qd, Exelon 4.6 mg patch qd
• PMH-HTN, Pernicious anemia, CAD, Depression, Mild
  Neuro Cognitive Disorder
• Does this patient have Delirium or Dementia?
• What other Diagnostic work would you do?
• Treatment Plan

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Dementia vs. Delirium

• Dementia is an acquired loss of intellectual
  functioning, occurring over a long period of
  time.
• Delirium is seen as a sudden change in
  mental functioning and/or acute confusion.

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Dementia vs. Delirium

• Delirium is commonly mistaken for dementia,
  depression, mania, acute schizophrenic
  exacerbation, or old age itself.
• To complicate matters, the patient may have both
  dementia with delirium or schizophrenia with
  delirium.
• The word is derived from a Latin root which
  means off the track.

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Dementia vs. Delirium

• Delirium is a state of cognitive impairment and
  confusion usually of recent onset related to
  other illnesses that can be resolved.
• The clinical hallmarks are decreased attention
  span and a waxing and waning type of confusion.
• Delirium means a sudden state of confusion that
  is considered a medical emergency with increased
  morbidity and mortality. It is NOT a disease but
  rather a syndrome with multiple possible causes.

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Statistics on Delirium

• Mortality rates are 10 to 26 for patients
  admitted to hospital with delirium.
• Patients who develop delirium while in hospital
  have a mortality rate of 22-76.

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Statistics on Delirium in the Elderly

• Based on another study of seventy-seven elderly
  patients who under went surgery, thirty-seven
  experienced post-operative delirium.
• None of these patients have any previous
  cognitive deficits prior to surgery.
• http//www3.interscience.wiley.com/journal/1187315
  28/abstract

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Statistics on Delirium in the Elderly

• In Acute Care
• 15 of older persons admitted to hospital have
  delirium
• 56 of older persons may develop delirium in
  hospital
• 30-40 of older persons become delirious after
  hip surgery

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Statistics on Delirium in the Elderly

• In Residential Care
• 40-60 of residents experience delirium
• In Home Community Care
• 42 of referrals to the Upper Island Geriatric
  Outreach Program were related to delirium
  (2003-2004).
• 90 chance a delirium will reoccur.
• http//www.viha.ca/NR/rdonlyres/4DC32399-96E8-401B
  -9AAB-126BDD8A3512/0/about_delirium_0807.pdf

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Statistics on Delirium in the Elderly

• Delirium complicates hospital stays for at least
  20 of the 12.5 million patients 65 years of age
  or older who are hospitalized each year, and
  increases hospital costs by 2,500 per patient.
  (USD-2004) (Inouye, 2006, p. 1157).
• http//www.viha.ca/NR/rdonlyres/4DC32399-96E8-401B
  -9AAB-126BDD8A3512/0/about_delirium_0807.pdf

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Delirium

• Delirium symptoms tend to fluctuate over the
  course of the day, with some improvement in the
  daytime and maximum disturbance at night.
• A reversal of the sleep-wake cycle is common.

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Reasons for Delirium

• D Dementia- a risk factor for delirium
• E Electrolyte Imbalances
• L Lung, liver, heart, kidney, brain
• I Infection
• R Rx drugs or substance abuse (may be
  intoxicated or withdrawing)
• I Injury, pain, stress
• U Unfamiliar Environment
• M Metabolic abnormalities

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• Despite there being a medical basis for the
  syndrome of delirium
• Laboratory and x-ray reports may be normal in
  over 33 of these patients.
• The main points to remember in identifying
  delirium include a sudden change in mental status
  over a few hours or days that is out of
  character for the patient.
• The patient is inattentive (cannot focus on
  your questions, poor eye contact, eyes closed,
  falling asleep are examples).
• The patient may fluctuate in the clarity from
  minute to minute with periods of clarity followed
  by periods of cloudy thinking.

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Delirium

• Delirium is based on clinical observation since
  there is no diagnostic test available.
• Labs/x-rays may look normal yet patient
  completely delirious. Delirium is STILL
  considered a medical illness with psychiatric
  symptoms
• Essential features of delirium
• Acute onset (hours/days)
• Fluctuating course
• Inattention or distraction
• Disorganized thinking
• Altered level of consciousness
• http//www.caregiver.on.ca/cgcihidmdl.html

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Medications and Delirium

• Medications/substances are the most common
  reversible cause of delirium.
• Medications contribute to about 40 of cases of
  delirium
• Diminished organ function
• Anticholinergic drugs
• Blood brain barrier drugs

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• Although the incidence of delirium is much higher
  in the elderly and dementia is a risk factor for
  delirium, it happens frequently in the general
  population as well.
• Never assume that someone who has a history of
  Bipolar and Schizophrenia is having an
  exacerbation of these disorders when they may in
  fact have delirium.
• Following the guidelines above and consider the
  Confusion Assessment Method (CAM)- remember just
  4 features, then we have a good sensitivity
  (positive in disease) and specificity (negative
  in health) of correct diagnosis.

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• The CONFUSION ASSESSMENT METHOD (CAM) is an
  easily administered test that is widely accepted
  by ICU nurses and physicians for the detection of
  delirium. There are four features to the CAM.
  To diagnose with delirium, the patient must have
  BOTH feature 1 and feature 2 AND either
  feature 3 or feature 4. Thus, three out of
  four features are usually present.

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 Feature 1 Acute onset and fluctuating
courseFeature 2 InattentionFeature 3
Disorganized thinkingFeature 4 Altered
Level of Consciousness
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Consider all systems as possible sources of
delirium from head to toe as well as the
possibility of multi-etiological delirium as
well. Provide reassurance to the patient,
proper lighting, and an attempt to not only
identify the cause but to restore the sleep-wake
cycle by stimulation during the day to promote
rest at night. Limit anti-histamines and
medications that are anticholinergic.
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Now that you have a possible diagnosis, what is
the workup? CBC, CMP including renal/liver
tests, TFTs, UA, UDS, thiamine and B-12 level,
tests for infection, HIV tests, oxygen sat. and
carbon dioxide retention etc. Consider
neurological causes such as CVA, TIA, and
seizures. Look for possible medication causes
test drug levels (lithium, Depakote, Dilantin,
Phenobarbital, etc.).
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Treatment of Delirium

• The role of pharmacologyspecifically
  antipsychotic and cholinesterase inhibitorsis
  unclear, though antipsychotics may be helpful for
  acute agitation or in regulating the sleep-wake
  cycle.
• This use, however, is off-label, and the most
  important aspect in managing delirium is
  identifying and treating the underlying medical
  cause.

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May need Haldol for extreme psychosis
(agitated hyperactive delirium) or alternative
when appropriate. This can be determined by
the level of associated agitation and psychosis
along with patient age and frailty as to the drug
used, dosage, frequency, and route of
administration.
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IV Haldol increases the risks for cardiac
complications such as torsade and attention to QT
prolongation and transfer to monitored beds
should be considered as per policy protocol.
May need benzodiazepines (lorazepam, oxazepam,
etc. for drug withdrawal delirium and
restlessness)Remember to administer thiamine
for actually 30 days in Alcoholics to limit the
risks for developing Wernickes encephalopathy.
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This syndrome is still greatly misunderstood and
is one of the number one reasons for hospital
admissions. There is also hospital acquired
delirium which has an even higher mortality rate
than delirium that presents on admission. The
quicker you can identify the correct diagnosis,
the better the prognosis and shorter hospital
stays
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Treatment of Delirium

• The optimal way to treat delirium is to identify
  and correct the underlying medical etiology,
  avoid unnecessary interventions (medications,
  medical devices), provide frequent reorientation
  and optimize the sleep-wake cycle, and avoid the
  use of restraints whenever possible.

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Nursing Interventions for Delirium

• Support nutrition and fluid intake to maintain
  electrolyte balance
• Return the person to their normal sleep pattern
  as soon as possible. Use environmental and
  natural approaches first (e.g., music, warm
  milk), and medication only when absolutely
  necessary and only for a short period of time.

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Nursing Interventions for Delirium

• Attend to environment
• Provide support to patient and family
• Provide close observation (social restraint)
• Keep patient safe and help them regain control.
• Provide good family communication education

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Dementia Vs Delirium

• Dementia is sustained, whereas, delirium is
  typically an acute and fluctuating state.
• Dementia is an irreversible state of cognitive
  impairment and short term memory loss related to
  organic brain disease or multiple cerebral
  infarcts.

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Statistics on Dementia

• According to the Alzheimers Association, as many
  as 5 million Americans are living with
  Alzheimers disease.
• It is the most common form of dementia,
  accounting for 50-70 of all cases.

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Statistics on Dementia

• Vascular dementia makes up a large portion of all
  dementia cases.
• Other cases included mixed (combination of
  Alzheimer and vascular), Parkinson's dementia,
  and dementia with Lewy bodies.

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In the Alzheimer's brain The cortex shrivels
up, damaging areas involved in thinking, planning
and remembering. Shrinkage is especially severe
in the hippocampus, an area of the cortex that
plays a key role in formation of new memories.
Ventricles (fluid-filled spaces within the
brain) grow larger
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Alzheimer's disease leads to nerve cell death and
tissue loss throughout the brain. Over time, the
brain shrinks dramatically, affecting nearly all
its functions. These images show A brain
without the disease A brain with advanced
Alzheimer's How the two brains compare
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Dementia Vs. Delirium

• Dementia under a Microscope

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Differentiating Delirium Dementia
Features Delirium Dementia
Onset Acute Insidious
Course Fluctuating Progressive
Duration Days to Weeks Months to Years
Consciousness Altered Clear
Attention Impaired Normal, except for severe dementia
Psychomotor changes Increased or Decreased Often normal
Reversibility Usually Rarely
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Screening Tool

• If cognitive impairment is identified on a Mini
  Mental Status Exam (Folstein, or MMSE), the CAM
  (Confusion Assessment Method) is then used to
  screen for delirium.
• http//www.viha.ca/NR/rdonlyres/4DC32399-96E8-401B
  -9AAB-126BDD8A3512/0/about_delirium_0807.pdf

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Treatment for Dementia

• Medications (Acetylcholinesterase inhibitors like
  aricept, razadyne, and exelon as well as NMDA
  receptor-active like namenda)
• Non-medical interventions include
• Provide a calm, safe environment
• Monitor personal comfort
• Avoid confrontation or arguments
• Redirect negative behaviors

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Diagnoses?

• How to treat patients with delirium complicated
  with dementia
• A. Safety
• B. Fluids, electrolytes, nutrition
• C. FAMILY COMMUNICATION/ EDUCATION/
  INFORMATION
• D. See source of offending agent if possible

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Diagnoses?

• E. Medications (individualized)
• scheduled haldol didnt do anything had to call
  MD for more PRNs.
• F. Appropriate Stimulation (ex. Ambulate pt with
  assistance at least BID.)

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Nursing Interventions for Dementia

• Support nutrition and fluid intake to maintain
  electrolyte balance
• Provide a supportive low stimulus environment
• Engage in simple activities or tasks
• Provide good family communication and education.

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Nursing Interventions for Dementia

• Try to redirect negative or unwanted behaviors at
  first sign of anxiousness (will help avoid PRNs)
• Avoid always correcting patient
• If redirection is unsuccessful use PRNs before
  the agitation/anxiety escalates into a
  potentially dangerous situation for patients or
  staff.

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Delirium in Dementia Patients

• Delirium is thought to occur 4-5 times more often
  in a dementia patient.
• Delirium superimposed on dementia is less likely
  to be recognized and treated, which can lead to
  life-threatening complications.

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Delirium in Dementia Patients

• In dementia patients, delirium can substantially
  worsen long-term outcomes, including prolonged
  hospitalization, further decline in cognitive and
  physical functioning, rehospitalization, nursing
  home placement, and death.

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Delirium in Dementia Patients

• Acute mental status changes in dementia patients
  are often attributed to the underlying dementia
  or sundowning.
• However, all dementia patients who experience an
  acute change in mental or physical functioning
  should be assessed for delirium superimposed on
  the dementia.

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Clinical Presentation Discussion
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Dementia and Delirium Review Questions
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• 1. Dementia is slow to develop and chronic as
  opposed to delirium which is acute in
  development.
• True or False
• 2. Vascular Dementia is the most common type of
  dementia since the year 2002.
• True or False
• 3. Delirium is commonly called metabolic
  encephalopathy when due to metabolic
  derangements.
• True or False
• Dementia is a risk factor for delirium
• True or False

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5. Visual hallucinations are the most common
type of hallucination in delirious patients.True
or False 6. Laboratory/x-ray work-up for
patients with a sudden change in mental status
include which?A. CBC with differentialB.
Urinalysis with culture and sensitivityC. Chest
x-rayD. Complete metabolic panelE. All of the
above are appropriate7. The optimal way to
treat delirium is to identify/correct the
cause.True or False
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8. All delirious patients are best treated on the
psychiatric unit. True or False9.
One of the most common causes of delirium in a
patient presenting from a nursing home is
A. Nicotine poisoning from
unremoved patches B.
Myocardial infarction
C. Urinary tract infection
D. Fatigue E.
Factitious disorder10. Wernickes
encephalopathy is a type of delirium seen in
alcoholics and is treated with?
A. Glucose B.
B-12 injection C.
Thiamine IV D.
Flumazenil (romazicon)

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Answer Key for Dementia and Delirium

• 1. True
• False
• True
• True
• True
• E all of the above
• True
• False
• C
• C

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Thank You