Delirium, Dementia

Question 0

Delirium investigations

Answer 0

• standard: CBC and differential, electrolytes, Ca2+, PO4
3-, Mg2+, glucose, ESR, LFTs, Cr, BUN, TSH, vitamin B12,
folate, albumin, urine C&S, R&M
• as indicated: ECG, CXR, CT head, toxicology/heavy metal screen, VDRL, HIV, LP, EEG (typically abnormal: generalized slowing or fast activity), blood cultures
• indications for CT head: focal neurological deficit, acute change in status, anticoagulant use, acute incontinence, gait abnormality, history of cancer

Question 1

Delirium etiology

Answer 1

I WATCH DEATH
• Infectious (encephalitis, meningitis, UTI, pneumonia)
• Withdrawal (alcohol, barbiturates, benzodiazepines)
• Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure)
• Trauma (head injury, postoperative)
• CNS pathology (stroke, hemorrhage, tumour, seizure disorder, Parkinson’s)
• Hypoxia (anemia, cardiac failure, pulmonary embolus)
• Deficiencies (vitamin B12, folic acid, thiamine)
• Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
• Acute vascular (shock, vasculitis, hypertensive encephalopathy)
• Toxins: substance use, sedatives, opioids (especially morphine), anesthetics, anticholinergics, anticonvulsants, dopaminergic agents, steroids, insulin, glyburide, antibiotics (especially quinolones), NSAIDs
• Heavy metals (arsenic, lead, mercury)

Question 2

Delirium management

Answer 2

• intrinsic
ƒ identify and treat underlying cause immediately
ƒ stop all non-essential medications
ƒ maintain nutrition, hydration, electrolyte balance and monitor vitals
• extrinsic
ƒ environment should be quiet and well lit
ƒ optimize hearing and vision
ƒ room near nursing station for closer observation; constant care if patient jumping out of bed, pulling out lines
ƒ family member present for reassurance and re-orientation
ƒ calendar, clock for orientation cues
• biological
ƒ low dose antipsychotics
ƒ haloperidol has the most evidence; reasonable alternatives include risperidone, olanzapine or quetiapine
ƒ benzodiazepines only to be used in alcohol withdrawal delirium; otherwise, can worsen delirium
• physical restraints if patient becomes violent

Question 3

Delirium Px

Answer 3

• up to 50% 1 yr mortality rate after episode of delirium

Question 4

The 4 As of Dementia (+1)

Answer 4

Amnesia
Aphasia
Apraxia
Agnosia
Disturbance in executive functioning (planning etc)

Question 5

Most common dementias

Answer 5

Alzheimer’s dementia comprises >50% of cases; vascular causes comprise approximately 15% of cases

Question 6

Investigations in dementia

Answer 6

Investigations (rule out reversible causes):
• standard: same as Delirium
• as indicated: VDRL, HIV, SPECT, CT head in dementia
• indications for CT head: same as for delirium, plus: age <2 yr), recent significant head trauma, unexplained neurological symptoms (new onset of severe headache/seizures)

Question 7

Management of dementia

Answer 7

• treat underlying medical problems and prevent others
• provide orientation cues for patient (e.g. clock, calendar)
• provide education and support for patient and family (e.g. day programs, respite care, support groups, home care)
• consider long-term care plan (nursing home) and power of attorney/living will
• inform Ministry of Transportation about patient’s inability to drive safely
• consider pharmacological therapy
ƒ cholinesterase inhibitors [e.g. donepezil (Aricept®)] for mild to severe disease
ƒ NMDA receptor antagonist (e.g. memantine) for moderate to severe disease
ƒ low-dose neuroleptics (e.g. risperidone, quetiapine), antidepressants or trazodone if
behavioural or emotional symptoms prominent – start low and go slow
ƒ reassess pharmacological therapy every 3 mo