Delirium and Dementia Flashcards
What is the definition of delirium?
A rapidly developing disorder of attention characterized by an inability to maintain a coherent line of thought. Also known as an acute confusional state.
What are the contrasting features of delirium and dementia?
Delirium: Acute disorder Fluctuating level of consciousness Impaired attention Incoherent speech Toxic and metabolic causes usually found Typically reversible
Dementia: Chronic disorder Normal level of consciousness Normal attention Aphasia Toxic and metabolic causes usually not found Typically irreversible
What is the more common form of delirium?
Hypoaroused: lethargy and somnolence
Less common- hyperaroused: agitation and restlessness (Delirium tremens from alcohol withdrawal)
What is the prevalence of delirium in hospitalized patients?
10-60% in elderly, 60-80% in ICU
About half of all hospitalized older people, and a majority of intensive care unit patients develop delirium, and the syndrome predicts a worse outcome.
What is the pathophysiological cause of delirium
Delirium represents diffuse brain dysfunction related to a disruption of normal brain homeostasis. Neuronal dysfunction is widespread, affecting arousal systems in the brainstem and diencephalon as well as cortical regions, but the most vulnerable neurons are thought to
be those involved in cholinergic, dopaminergic, histaminergic, noradrenergic, and serotonergic neurotransmission.
What are the common causes of delirium
drugs and toxins (intoxication or withdrawal), metabolic disorders, infection/inflammation, structural lesions, seizure disorders
What can be done for delirium?
Withdraw agitating factors, manipulate environment, provide adequate sleep (trazodone, zolpidem QHS), Drugs for agitation (Atypical antipsychotics or benzodiazepines PRN- always at lowest possible dose)
What is Dementia?
Acquired and persistent impairment of intellectual function or cognition in at least three domains, sufficient in severity to interfere with social and occupational function.
What is the most common cause of dementia?
Alzheimer’s disease ~5million in US
What causes dementia?
Reversible: drugs and toxins, mass lesions, normal pressure hydrocephalus, systemic illness, Inflammatory diseases (neurosyphilis, SLE), depression, mild traumatic brain injury
Irreversible (80-90%): Alzheimer’s, frontotemporal lobar degeneration, vascular dementia, Lewy Body, Parkinson’s, Huntington’s, HIV assoctiated, moderate and severe traumatic brain injury
Evaluation of Dementia?
History and physical examination (general, neurologic, mental status)
CMP, CBC, TSH, B12, RPR
MRI or CT scan of the brain
In selected cases: neuropsychological testing, lumbar puncture, EEG, HIV, ESR, antibodies for autoimmune dementia, ceruloplasmin for Wilson’s Disease, heavy metal screening, genetic testing, cerebral angiography, brain biopsy
How can Dementia be classified?
By site of involvement: cortical- Alzheimer's subcortical- Parkinson's White matter- Binswanger's Mixed- multiple infarcts
What is necessary to be found for a definitive diagnosis of Alzheimer’s?
neuritic plaques and neurofibrillary tangles in neocortex and hippocampus
How long do people survive after onset of AD?
6-12 years
What are the symptoms of the first stage of AD?
1-3 years- initial amnesia, mild anomia, apathy
What are the symptoms of the second stage of AD?
2-10 years- marked amnesia, fluent aphasia, visuospatial dysfunction, anosognosia, neuropsychotic features.
What are the symptoms of the third stage of AD?
8-12 years- severe dementia, global aphasia or mutism, incontinence
What is Mild cognitive impairment?
Memory complaint, preferably corroborated by an informant
Objective evidence of memory impairment for age and education
Largely normal general cognitive function
Essentially intact daily living activities
No dementia
More likely to develop AD
What are the gross findings in AD?
Cerebral atrophy, cortical neuronal and synaptic loss, mostly limbic and association cortices (higher function)
What are the causes of AD?
Unknown, but htn, diabetes, and TBI are implicated
What are the genetic associations with AD?
Trisomy 21, PSEN-1, PSEN-2, APOE
What is frontotemporal dementia
Cortical dementia that selectively affects frontal and temporal lobes (hippocampus is spared until late in disease state). Behavioral disorder before memory loss. Disinhibition and apathy
What is Parkinson’s dz?
Loss of dopaminergic cell n the substantia nigra.
What is huntington’s dz?
Autosomal Dominant. Early personality changes with dementia and chorea
What is Binswanger’s disease?
Vascular dementia related to multiple white matter infarcts. MRI is preferred test
What is normal pressure hydrocephalus?
Potentially reversible. Can use shunts, but there are often complications.
What is multi-infarct dementia?
Combination of strokes lead to progressive dementia
What is creutzfeldt-Jakob dz?
Rapid prion disease that leads to dementia, acute confusion, hallucinations, and delusions
What is creutzfeldt-Jakob dz?
Rapid prion disease that leads to dementia, acute confusion, hallucinations, and delusions
Use diffusion MRI- shows cortical or deep gray matter hyperintensity
What is the treatment for dementia?
INFORMED COUNSELING, avoid benzodiazepines, cholinesterase inhibitors (donepezil, rivastigmine, galantamine), Memantine (NMDA antagonist)
Behavioral measures to treat neuropsychiatric syndromes. Use drugs sparingly.
What is the differential diagnosis for delirium?
Dementia, amnesia, and aphasia
schizophrenia, mania, or depression(but usually no fluctuation in level of consciousness)
How do you evaluate for delirium?
It is typically difficult to do a mental status exam, so you usually just document ‘confused state’ in the note. Routine lab tests should be done: H&P, CMP, CBC, urinalysis, electrocardiogram, chest radiograph, tox screen, CT or MRI, LP, EEG.
