Delirium and Dementia

Question 1

What is a delirium?

Answer 1

Also known as Toxic Confusional State or Acute Organic Psychosis – Acute or Subacute Brain Failure; Impairment of Attention associated with Abnormalities of Perception and Mood
o DSM-IV Criteria – Disturbance of Consciousness (Reduced Environmental Awareness
and Reduced ability to Focus, Sustain or Shift Attention), Change in Cognition
(Memory, Orientation, Language, Perception); Disturbance should develop over a short period (hours/days) and Fluctuates over course of a day

Question 2

Progression of Delirium

Answer 2

Confusion is usually worse at night with consequent Sleep Reversal; During the Acute phase, Thought and Speech are incoherent, Memory is impaired and Misconceptions can occur; Episodic Visual Hallucinations/Illusions and Persecutory Delusions occur

Question 3

Differentials for Delirium

Answer 3

Developing, Deteriorating or Damaged brains are predisposed to Delirium; Differential should
include Delirium tremens (ETOH XS) and Lewy Body Dementia

Question 4

Management of Delirium

Answer 4

• Collateral History and thorough examination of the patient could reveal cause
• Patient should be nurse and rehydrated in quiet single room etc
• Blood Tests – FBC, CRP, U/Es, LFTs, Thiamine, Vitamin B12 and Folate, Glucose, TFTs, Cortisol;
Imaging (CXR, CT/MRI Head if indicated), Consider Drug/Alcohol intoxication and review current Drug therapy
o Antipyretics should be given if febrile; Psychoactive drugs avoided

Question 5

Management of Severe Delirium

Answer 5

Haloperidol is effective; Benzodiazepines should not be used as first-line
and may even prolong confusion

Question 6

How long does delirium last?

Answer 6

Delirium usually clears within a week or two; Prognosis depends on successful treatment of causative disease as well as underlying state of brain
o 25% of Delirious Elderly have underlying Dementia; 15% due to survive underlying illness and 40% are in institutional care at 6 months

Question 7

What is dementia?

Answer 7

• Clinical Syndrome with multiple causes; Defined
by Acquired loss of Higher Mental function affecting two or more cognitive domains (Episodic Memory, Language, Frontal Executive, Visuospatial Function, Apraxia or Agnosia)
• Of sufficient severity to significantly cause
Social/Occupational Impairment occurring in
Clear Consciousness (C/f Delirium)

Question 8

Mild Cognitive Impairment

Answer 8

Intermediate state between Normal Cognition and Dementia; Might often be only Memory Impairment
(Amnestic MCI)
o Might be “Pre-dementia” state; 10-15% MCI patients develop Alzheimer’s Disease

Question 9

Assessment of Dementia

Answer 9

• MMSE – Relatively insensitive to milder cognitive impairment and Frontal Lobe Dysfunction
o Addenbrooke’s Cognitive Examination (ACE) – Addresses deficiencies in MMSE
• Individual Cognitive Domains tested separately – Clock drawing (Parietal), Naming and Reading Tasks (Language), Verbal Fluency, Cognitive Estimation and Stop-go Tasks for Frontal
Lobe Function (Frontal Assessment Battery), Recall Recent News Events (Episodic Memory)
• Primitive Reflexes (Frontal Release Signs) e.g. Grasp, Palmo-mental and Pout reflexes, perseveration or Utilisation Behaviour
• Praxis – Copying Hand Gestures and Miming
• Complete Neurological Examination including
looking for evidence of Papilloedema, Parkinsonism, Myoclonus, Gait disturbance

Question 10

Investigations in Dementia

Answer 10

• Blood Tests – FBC, Vitamin B12, TFT, U/Es, LFTs,
Glucose and ESR
• CT for excluding Structural lesions (E.g. Tumours, Hydrocephalus); MRI helps identify patterns of regional brain atrophy to distinguish between different types of
degenerative dementia
• Detailed Neuropsychometric Assessments for
quantification and tracking deterioration
• Younger patients <65yrs should have more
intensive investigations, including EEG, Genetic
Testing (Huntington’s, Familial Alzheimer’s Disease), HIV Serology, Metabolic tests etc

Question 11

Management of Dementia

Answer 11

• Management is supportive; Preserve Dignity and Provide care for as long as possible within the home environment
• Multidisciplinary Team includes Dementia Clinical Nurse Specialists, Geriatricians, OT/PT
• Participation in Cognitively Demanding activities in later life might delay onset; High dose B Vitamins might slow conversion of MCI to Alzheimer’s Disease
• Cholinesterase Inhibitors (Donepezil, Rivastigmine, Galantamine) inhibit CNS

Question 12

When should cholinesterase inhibitors be used or not?

Answer 12

Effective in Dementia with

Lewy Bodies and Parkinson’s Dementia but not in Frontotemporal or Vascular Dementia

Question 13

Memantine

Answer 13

NMDA Receptor Antagonist; Used in Moderate/Severe AD where Cholinesterase Inhibitors not tolerated