29: 72-year-old man with dementia

Question 1

Major Neurocognitive Disorder - DSM Criteria

Answer 1

DSM V Criteria for Major Neurocognitive Disorder (previously termed “dementia”)
A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains:
Learning and memory Language
Executive function Complex attention Perceptual-motor Social cognition
B. The cognitive deficits interfere with independence in everyday activities. At a minimum, assistance should be required with complex Instrumental Activities of Daily Living (IADL), such as paying bills or managing medications.
C. The cognitive deficits do not occur exclusively in the context of a delirium
D. The cognitive deficits are not better explained by another mental disorder (eg, major depressive disorder, schizophrenia)

Question 2

Most Common Causes of Dementia

Answer 2

Alzheimer’s accounts for approximately 60% of all cases of dementia and is therefore the most likely etiology in most cases. The differential diagnosis of dementia is fairly long, however; and other causes need to be considered. New criteria and guidelines identify three stages of Alzheimer’s disease:
1. preclinical Alzheimer’s disease
2. mild cognitive impairment (MCI) due to Alzheimer’s disease (MCI) 3. dementia due to Alzheimer’s disease.
These reflect current thinking that changes in the brain begin years before symptoms are apparent.

Vascular dementia (e.g. due to multiple infarcts) accounts for about 15-20% of causes. Patients with this diagnosis usually have cardiovascular risk factors such as hypertension and tobacco use. Approximately 10% of patients with Alzheimer’s dementia also have pathologic findings of vascular dementia and may be considered to have mixed dementia.

Dementia with Lewy bodies (DLB) has recently been recognized as a more common cause of dementia than previously thought, accounting for 10% to 15% of cases at autopsy. In addition to typical symptoms of dementia, patients with DLB manifest fluctuations in alertness and attention (delirium), visual hallucinations, and Parkinsonian symptoms.

Question 3

Less Common Causes of Dementia

Answer 3

Parkinson’s disease is a cause of dementia late in the course of the disease, with the prominent motor symptoms starting years before. This sequence distinguishes dementia from Parkinson’s from DLB, in which the Parkinsonian symptoms and dementia begin simultaneously. Patients presenting with dementia without the classic findings of Parkinson’s are unlikely to have Parkinson’s disease.

Frontal temporal dementia, such as Pick’s disease, differs from Alzheimer’s because, as the name implies, this type of dementia presents with more frontal lobe symptoms (such as changes in personality, demeanor, and behavior).

Other rare forms include Huntington’s disease and Creutzfeldt-Jakob disease. Huntington’s disease follows an autosomal dominant pattern and therefore typically has a strong family history. Its initial presentation is characterized by random, jerky and uncontrollable movements (choreiform movements). Creutzfeldt-Jakob disease is an extremely rare, rapidly progressive infectious condition transmitted by a prion.

Question 4

Ankle Clonus

Answer 4

A series of abnormal alternating contractions and relaxations of the foot induced by sudden dorsiflexion of the foot. Its presence is suggestive of upper motor neuron pathology.

Question 5

Primitive Reflexes

Answer 5

Patients with advanced dementia or other neurodegenerative diseases may develop primitive reflexes with loss of frontal lobe control. Primitive reflexes are those that may be seen in infants, including grasp, suck, and the “glabellar tap” (patient continues to blink each time he or she is tapped on the forehead; healthy patients stop blinking after the second or third tap).

Question 6

Long-term care such as nursing home or adult day program

Answer 6

If there is a need for skilled services, Medicare will cover 100% of the cost for the first 20 days of a nursing home stay after a hospitalization.

Long-term care is not covered at all, however. Adult day programs cost anywhere from 50 to 100 dollars a day, while nursing homes cost between 150 and 250 dollars a day.

Question 7

UTI Tx

Answer 7

Treat UTI with IV ceftriaxone after making certain that the urine sample gets sent for gram stain and culture.

Question 8

Delirium Treatment

Answer 8

Prescribe a short course of oral haloperidol, which is helpful in aiding sleep, diminishing agitation, and clearing hallucinations.

Some providers prefer newer atypical antipsychotics such as olanzapine and quetiapine, which have fewer extrapyramidal side effects. There is a recent systematic review of the efficacy and safety of the off-label use of atypical antipsychotic medications for various conditions. For symptoms such as psychosis, mood alterations, and aggression associated with dementia in elderly patients, small but statistically significant benefits were observed for aripiprazole, olanzapine, and risperidone. However, these agents can lead to a prolonged QT interval and don’t have the long track record of haloperidol.

Question 9

Side effects of haloperidol:

Answer 9

Somewhat sedating and can cause constipation.

Tardive dyskinesia - involuntary spasms of the neck, tongue and lips. Generally seen in patients on higher doses of this medication for a long time (such as over a year).

QT prolongation - rare.

Question 10

Hospital Interventions That Can Prevent or Minimize Delirium

Answer 10

• frequent reorientation and redirection by a familiar provider
• avoid meds that can lead to delirium
• provide early mobility and ROM exercises
• minimize unnecessary lines, cables, and catheters
• provide increased stimulation

Question 11

Treatment of Alzheimer’s Dementia & Symptoms

Answer 11

• cholinesterase inhibitors
• Vit E
• Memantine
• Respite
• atypical antipsychotics

Question 12

Cholinesterase inhibitors

Answer 12

Four cholinesterase inhibitors (donepezil, rivastigmine, tacrine and galantamine) show
statistically significant, though clinically small benefits for patients with mild to moderate dementia.

Question 13

Memantine (Namenda)

Answer 13

is an N-methyl d-aspartate (NMDA) receptor antagonist that is FDA- approved for use in moderate to severe dementia. Randomized trials suggest that, like the cholinesterase inhibitors, memantine leads to small but statistically significant improvements in cognition.

Question 14

atypical antipsychotics

Answer 14

The atypical antipsychotics olanzapine (Zyprexa) and risperidone (Risperdal) appear to have a modest benefit in managing such neuropsychiatric symptoms and are commonly used.

Question 15

Diagnosing Delirium

Answer 15

The Confusion Assessment Method (CAM) has been widely used over two decades and is the predominant tool used in clinical research regarding delirium.

A recent systematic review of assessment tools in diagnosing the presence of delirium demonstrated that the best evidence supports use of the CAM, which takes five minutes to administer. The CAM has a summary-positive likelihood ratio of 9.6 (95% CI, 5.8 - 16.0) as a bedside delirium instrument.

The MMSE, which has been widely used clinically during the same time period, is a multidimensional tool to assess cognitive function, and was not developed specifically for the assessment of delirium. In the same study mentioned above, the MMSE was the least useful in identifying a patient with delirium (likelihood ratio, 1.6; 95% CI, 1.2 - 2.0).

A newer test, the Montreal Cognitive Assessment (MoCA), has been proposed to be a better alternative than the MMSE to assess cognitive function.

Question 16

ADLs

Answer 16

bathing 
dressing 
transferring 
continence 
toileting 
feeding

The most basic skills that patients need to stay independent and live at home. They represent one’s basic personal care and physical ability.

Question 17

IADLs

Answer 17

shopping
preparing meal
using the telephone
managing transportation needs 
managing medications 
managing finances

These don't have to be done on a daily basis, are not as severe a threat to independent living, and other people can be hired to do them. They typically require a cognitive component in addition to physical ability.

Over 50% of people over the age of 75 have at least one IADL deficit.

Question 18

Air bronchograms

Answer 18

Sometimes air-bronchograms are visible in the infiltrate. Air bronchograms are l inear lucencies within an infiltrate that represent the air within a bronchus that is surrounded by consolidated lung tissue. These are pathognomonic for an airspace illness such as pneumonia.

Question 19

Dementia

Answer 19

Dementia is an acquired syndrome of gradual progressive deterioration in global intellectual ability that interferes with the ability to function in social and occupational roles.

Important elements of the definition include: acquired (i.e., not congenital), progressive (i.e., worse over time), global (not isolated to memory), and interfering with function.

Question 20

Delirium

Answer 20

Delirium also causes a decline in cognition, but is particularly notable for acute disturbances in attention (e.g., an inability to shift focus), alertness (e.g., impaired consciousness and sleep cycles) and perception (e.g., hallucinations).

In delirium, the symptoms fluctuate over short periods of time, whereas in dementia the symptoms are slowly progressive.

Question 21

Depression

Answer 21

Depression is an alteration in mood, which can be confused with dementia in older patients. It frequently causes a decline in the ability to concentrate, which may worsen memory. Depression also leads to a lack of interest and energy, which may appear similar to the symptoms of dementia. Since depression is readily treatable, it is essential to diagnose this condition in patients who present with memory loss.

In addition to representing the primary diagnosis, depression can be comorbid with dementia, and should be considered both because it may worsen symptoms related to dementia, and because it can be reversible.

Question 22

Differential Diagnosis of Change in Mental Status in a Patient with Dementia; Most Likely Diagnoses Causes of delirium:

Answer 22

• UTI
• respiratory infection
• electrolyte disturbance
• urinary retention
• pain
• depression
• withdrawal
• acute cerebrovascular events
• adverse drug reactions

Question 23

adverse drug effects

Answer 23

As a group, adverse drug effects represents one of the most common causes of delirium in older patients. Patients with dementia, in particular, are sensitive to medications with sedating effects. Medications with anticholinergic effects (opiates, benzodiazepines, sedating antihistamines, tricyclic antidepressants, antipsychotics, and some anti-nausea medications) are the drugs most likely to cause delirium. Other potential offenders include certain antibiotics (e.g. fluoroquinolones), beta-blockers, and H2-blockers.

Question 24

Acute cerebrovascular events

Answer 24

such as ischemic stroke or intracranial bleeding may present with an acute change in mental status.

This is most likely in a patient with vascular dementia who experiences a new ischemic event. In this case, the vascular event could be small enough to not cause new neurologic symptoms. In combination with the other pre-existing insults, however, the new event may cause an acute alteration in mental status.

Large brain insults (e.g. those due to larger ischemic events or acute hemorrhage) typically have associated neurological findings on physical exam (e.g. hemiplegia or upper motor neuron findings - such as hyperreflexia, clonus, or positive Babinski’s).

Question 25

Any condition that leads to discomfort may cause delirium in a patient with dementia. Acute urinary retention…

Answer 25

…leads to the complete inability to pass urine. Chronic urinary retention (most commonly due to benign prostatic hypertrophy [BPH]), however, leads to incomplete emptying and distention of the bladder, which further may lead to UTI and overflow incontinence. Risk factors for urinary retention include male sex, age over 70 and BPH.

When this is a consideration, a post void residual should be measured (either by catheterization or ultrasound assessment of bladder volume after voiding). Catheterization allows the collection of a urine culture that is unlikely to be contaminated by skin flora. When urinary retention is severe, the bladder may be palpated in the suprapubic area.