Dementia and Delirium

Question 1

Why do we care about dementia?

• “_______” population
  
  • By 2030, there may be 70 million elderly in the US (currently around 35 million)
• Current prevalence rates of dementia
  
  • 6-8% if older than ___
  • 30% if older than ___

Answer 1

• “Graying” population
  
  • By 2030, there may be 70 million elderly in the US (currently around 35 million)
• Current prevalence rates of dementia
  
  • 6-8% if older than 65
  • 30% if older than 80

Question 2

Screening for Cognitive Impairment: Policy Update

• _________ benefit: Annual Wellness Visit
  
  • Cognitive assessment for ______ detection
  • Personalized health ____ assessment (HRA) and _____ plan
• Incentives
  
  • For patients: ___ deductible or co-pay
  • For physicians: _________ equivalent to Level 4 E/M

Answer 2

• Medicare benefit: Annual Wellness Visit
  
  • Cognitive assessment for early detection
  • Personalized health risk assessment (HRA) and prevention plan
• Incentives
  
  • For patients: no deductible or co-pay
  • For physicians: reimbursement equivalent to Level 4 E/M

Question 3

What is Dementia?

• Impairment in ______ function affecting more than one ______ domains
• Interferes with s_____ or o______ function
• De____ from a previous level
• Not explained by de_____ or major ______ disease

Answer 3

• Impairment in intellectual function affecting more than one cognitive domains
• Interferes with social or occupational function
• Decline from a previous level
• Not explained by delirium or major psychiatric disease

Question 4

Cognitive Domains

• (1) (frontal, hemispheric white matter)
• (1) (medial temporal lobes/hippocampus)
• (1) (left hemisphere, usually)
• (1) (occipital, parietal)

Answer 4

• Executive function (frontal, hemispheric white matter)
• Memory (medial temporal lobes/hippocampus)
• Language (left hemisphere, usually)
• Visuospatial (occipital, parietal)

Question 5

Aphasia

• Able to in____ and m______ a conversation
• Impaired com________
• Intact (2) however the speech is _____ with _____phasias, cir______, t_______and often using non______ phrases (“the thing”)
• Later language can be severely impaired with m_____, e______

Answer 5

• Able to initiate and maintain a conversation
• Impaired comprehension
• Intact grammar and syntax however the speech is vague with paraphasias, circumlocutions, tangential and often using nonspecific phrases (“the thing”)
• Later language can be severely impaired with mutism, echolalia

Question 6

Apraxia

=

Contributes to loss of (1)

Answer 6

Inability to carry out motor activities despite intact motor function

Contributes to loss of ADLs

Question 7

DSM 5 Criteria

(5)

Answer 7

• Dementia of the Alzheimer’s Type (DAT)
• Dementia of the Vascular Type
• Dementia with Lewy Bodies
• Frontotemporal Dementia
• Delirium

Collaboration, collaboration, collaboration, + consulting* (geriatric specialist)

Question 8

Dementia Subtypes

• Early onset =
  
  • Represents what % of cases?
  • Strong _____ link
  • Tends to progress more ______
• Late onset =
  
  • Represents _____ of cases

Answer 8

• Early onset: before the age of 60
  
  • Less than 5% of all cases of AD
  • Strong genetic link
  • Tends to progress more rapidly
• Late onset: after age 60
  
  • Represents the majority of cases

Question 9

Alzheimer Disease

=

• ______ neurodegenerative and dementing disease
• Prevalence ____ every 5 years after 65, ~___% of those older than ___
• Confirmation of Diagnosis =

Answer 9

Progressive neurological condition characterized by the buildup of proteins in the brain called “plaques” and “tangles”

• Commonest neurodegenerative and dementing disease
• Prevalence doubles every 5 years after 65; ~50% of those older than 85
• Confirmation of Diagnosis is dependent on brain biopsy after death*

Question 10

Alzheimer’s Risk Factors

• A___
• (1) positivity
• ______ History in (1) (especially if ______ onset)
• (1) (diabetes, heart disease, etc)
• Low (3)
• ______ sex

Answer 10

• Age
• ApoE-e4 positivity
• Family History in first degree relative (especially if younger onset)
• Vascular risk (diabetes, heart disease, etc)
• Low education and physical/social activity
• Female sex

Question 11

Alzheimers Clinical Features

1. First noticeable symptom?
2. Earliest cognitive symptoms (2)
3. Pattern of decline?
4. Other domains develop when?

Answer 11

Increasing memory loss over time is often the first noticeable symptom

Earliest cognitive symptoms are usually poor short term memory; loss of orientation

Smooth, usually slow decline without dramatic short-term fluctuations

Other domains involved with time

Question 12

Alzheimers Common Signs

• Getting stuck for _____ or ______ difficulties
• ________ things (names, dates, places)
• loss of (1)
• difficulty in solving (1) or performing (1)
• mis_____ things
• poor or decreased (1)
• changes in m_____, b_____, and overall p________
• Easily dis______, even in ______ surroundings

Answer 12

• Getting stuck for words or language difficulties
• Forgetting things (names, dates, places)
• Loss of interest in things previously interested in
• Difficulty in solving problems or performing everyday tasks
• Misplacing things
• Poor or decreased judgment
• Changes in mood, behavior, and overall personality
• Easily disorientated, even in familiar surroundings

Question 13

Alzheimers Behaviors and Psych

• (1), anxiety
• _____ty, _____ty, _____thy
• D______, H______
• S____-w____ changes
• S_________
• Ag______
• Important to also screen for depression using (1)

Answer 13

• Depression, anxiety
• Irritability, hostility, apathy
• Delusions, hallucinations
• Sleep-wake changes
• Sundowning
• Agitation
• Important to also screen for depression using Geriatric depression scale

Question 14

Anatomical Changes of the Brain

Mild/Moderate vs. Severe Alzheimers

Answer 14

• Shrinkage of hippocampus, Cortical shrinkage, Moderately enlarged ventricles
• Extreme shrinkage of hippocampus, Extreme shrinkage of cerebral cortex, Severely enlarged ventricles

Question 15

Lewy Body Dementia

• % of all dementias?
• Relatively earlier (2) degeneration
• Similar to _______ disease dementia

Answer 15

• 20% of all causes of dementia
• Occipital and Basal Ganglia degeneration
• Similar to Parkinson disease dementia

Question 16

Lewy Body Dementia Characteristics

• Progressive decline in N_______ functioning
• D_______, Le_____
• Lengthy periods of ______ into _____
• Disorganized ______
• Visual _______* or delusions
• Motor symptoms including muscle _____ and loss of (1)
• ________ is also common

Answer 16

• Progressive decline in Neurocognitive functioning
• Drowsiness, Lethargy
• Lengthy periods of staring into space
• Disorganized speech
• Visual hallucinations* or delusions
• Muscle rigidity, loss of spontaneous movement
• Depression is also common

Question 17

Lewy Body Dementia

Earliest symptoms (2)

Answer 17

Visuospatial and Executive

• Executive like balancing checkbook, visuospatial like climbing stairs
• Concerned for delirium on top of dementia

Question 18

Lewy Body Dementia Core Features

• ________ism
• Recurrent early (1)*
• Fl________ (clue: recurrent (1) evaluations)
• Suggestive features include (1) (dream enactment) & neuroleptic sensitivity

Answer 18

• Parkinsonism
• Recurrent early visual hallucinations
• Fluctuations (clue: recurrent DELIRIUM evaluations)
• Suggestive features include REM sleep disorder (dream enactment) & neuroleptic sensitivity

Question 19

Frontotemporal Dementia (FTD)

Arises from?

Originally known as?

Characterized by changes in (2) lobes that control (4)

Answer 19

Pathologic aggregates of Tau protein (TDP-43)

Pick’s disease

Frontal and Temporal lobes of the brain that control reasoning, personality, social behavior, and speech

Question 20

Frontotemporal Dementia Prevalence

Usually seen in what population?

Can you diagnose it with an MRI?

Answer 20

• Usually are YOUNG and need to screen for PSYCHIATRIC DISORDERS*
• MRI is not diagnostic but will show structural abnormalities can help indicate FTD vs. LBD vs. Alzheimers*

Question 21

Frontotemporal Dementia Characteristics

• FTD manifested by changes in (2)
• (2) change (may be initially misdiagnosed as a psychiatric disorder)
• E______ dysfunction
• Progressive non-fluent _______
• May see ____sonism or _____ weakness

Answer 21

• Behavior and Language
• Behavior and personality change (may be initially misdiagnosed as a psychiatric disorder)
• Executive dysfunction
• Progressive non-fluent aphasia
• May see parkinsonism or muscle weakness

Question 22

Vascular Dementia

=

“Evidence of (1) disease involving subcortical _____ matter”

• This finding is nondiagnostic and very _____ with age
• Changes may or may not be ______
• Don’t tell patients what?

Answer 22

Caused by multiple infarcts that lead to a disruption in blood flow to the brain

“chronic small vessel disease involving subcortical white matter”

• common with age
• may or may not be symptomatic
• Don’t tell patients “your scan showed strokes” - this is chronic small vessel/vascular dementia, not actual CVAs”

Question 23

Vascular Dementia

Suspect when

• Onset is (1) and/or (1) decline
• Course is (1)
• H/O (1)

Answer 23

• abrupt, stepwise decline
• fluctuating
• H/O stroke

Question 24

Vascular Dementia

Often associated with _______ dysfunction, ____ disorder, A_____, In_______

• Common presenting symptoms include
  
  • C_______, ____ term memory deficits
  • W_______, getting lost in ______ places
  • Gait is (2)
  • Loss of (2) control
  • (2) inappropriately
  • Difficulty following _______ and problems counting/making _____ transactions

Answer 24

Executive dysfunction, Gait disorder, Apathy, Incontinence

• Confusion, short term memory deficits
• Wandering, getting lost in familiar places
• Rapid, shuffling gait
• Loss of bowel and bladder control
• Laughing or crying inappropriately
• Difficulty following instructions and problems counting/making money transactions

Question 25

What type of Dementia is this?

1. Gradual impairment in memory, functional status, and other areas of cognition
2. Plateaus in course of progression, associated depression, insomnia

Answer 25

Alzheimer’s

Question 26

What type of Dementia is this?

1. Sudden onset of cognitive impairment in setting of stroke and/or risk factors of stroke
2. Focal neurological signs on exam; neuroimaging evidence of previous stroke; presence of HTN, DM, CAD, ⇡ lipids

Answer 26

Vascular (multi infarct) Dementia

Question 27

What type of Dementia is this?

1. Deficits in attention and executive function. Memory impairment may no be evident
2. Fluctuating cognition, recurrent visual hallucinations, motor features of parkinsonism, recurrent falls

Answer 27

Lewy Body Dementia

Question 28

What type of Dementia is this?

1. Gait disorder mimicking Parkinson’s, dementia, urinary incontinence
2. Shuffling, broad based gait, improvement following large volume spinal tap

Answer 28

Normal Pressure Hydrocephalus

Normal pressure hydrocephalus - usually treated/cured with shunt placement, patient will get better

Question 29

Steps to take in Dementia Evaluation

• H_____
• P_____ and N______ Exam
• C______ Screening Test
• Rule out _______ Causes
• Neuro______
• Consider the Et______
• Treatment or R_______ (**in NY there are many memory centers, but PCP may be required for basic labs and imaging)

Answer 29

• History
• Physical and Neurological Exam
• Cognitive Screening Test
• Rule out Reversible Causes
• Neuroimaging
• Consider the Etiology
• Treatment or Referral (**in NY there are many memory centers, but PCP may be required for basic labs and imaging)

Question 30

History Taking

• Patient will “_____” their memory problems
  
  • Get history from ____ or _____, if possible.
  • Memory impairment may be evidenced by repetitive ______, ____writing, _____ objects, etc
  • Ask about ______ impairment
  • Ask about (1) to assess functioning
  • Dementia is not just (1)!
  • Next step = _______ screening test

Answer 30

• Patient will “forget” their memory problems
  
  • Get history from caregiver or spouse, if possible.
  • Memory impairment may be evidenced by repetitive questioning, list writing, lost objects, etc
  • Ask about memory impairment
  • Ask about daily activities to assess functioning
  • Dementia is not just memory impairment!
  • Next step = cognitive screening test

Question 31

Features Associated with Dementia

1. Ag____
2. Ag________
3. S_____ disturbances
4. A______ (can be misdiagnosed as depression)
5. De______ or an____
6. P______ changes
7. B______ disinhibition
8. _______ insight
9. (1) (visual more common than auditory)
10. (1) (often paranoid or persecutory)

Answer 31

1. Agitation
2. Aggression
3. Sleep disturbances
4. Apathy (can be misdiagnosed as depression)
5. Depression or anxiety
6. Personality changes
7. Behavioral disinhibition
8. Impaired insight
9. Hallucinations (visual more common than auditory)
10. Delusions (often paranoid or persecutory)

Question 32

ADLs

(6)

Answer 32

• Bathing
• Dressing
• Grooming
• Toileting
• Continence
• Transferring

Question 33

IADLs

(7)

Answer 33

• Telephone
• Travel
• Shopping
• Meals
• Housework
• Medicine
• Money

Question 34

PMH/Social

• M_____ problems and ____ factors
• Neurologic history (st____, tr____, in_____)
• Ed_____ background
• F______ history
• Al____ and d_____
• M________
• Remember, your first goal is to exclude (1)

Answer 34

• Medical problems and risk factors
• Neurologic history (stroke, trauma, infection)
• Education background
• Family history
• Alcohol and drugs
• Medications
• Remember, your first goal is to exclude readily treatable causes…

Question 35

Impaired Executive Function

• Difficulty with pl____, in____, sequencing, monitoring or stopping complex ______
  
  • Contributes to loss of ________ activities of ADLs such as shopping, meal preparation, driving and managing finances

Answer 35

• Difficulty with planning, initiating, sequencing, monitoring or stopping complex behaviors
  
  • Contributes to loss of instrumental activities of ADLs such as shopping, meal preparation, driving and managing finances

Question 36

Importance of Cognitive Screening

• Establish a ______ level of functioning
• Allows for ______ documentation of cognition
• Cognitive Impairment is often?

Answer 36

• Establish a baseline level of functioning
• Allows for objective documentation of cognition
• Cognitive Impairment is often not documented

Question 37

Screening Tests

Answer 37

• Mini-Mental State Exam (MMSE)
• Clock Drawing Test (CDT)
• Mini-Cog
• Time and Change
• 7-Minute Screen
• Montreal Cognitive Assessment (MoCA)

Question 38

Mini Mental Status Exam

• O______ (10 points)
• Re________ (3 points)
• A______ and Ca________ (5 points)
• Re_____ (3 points)
• L_______ (8 points)
• V________ (1 point)
• Total=___, if less than ____, consider dementia, ___-___= moderate,

Answer 38

• Orientation (10 points)
• Registration (3 points)
• Attention and Calculation (5 points)
• Recall (3 points)
• Language (8 points)
• Visuospatial (1 point)
• Total=30, if less than 25, consider dementia, 13-20 = moderate, <12 = severe

Question 39

Clock Drawing Test

Part of the (1)

There are certain times providers are suggested to use, ie (1)

Answer 39

Mini Cog

11 after 9

Question 40

Mini Cog

=

• More sensitive than CDT
• Same advantages as CDT
• Not as commonly used as MMSE, but FAST
• Involves visuospatial, executive and planning, and memory functions
• “Positive” = ___ word recall/ ______ clock

Answer 40

Clock-Drawing + three item memory test

• More sensitive than CDT
• Same advantages as CDT
• Not as commonly used as MMSE, but FAST
• Involves visuospatial, executive and planning, and memory functions
• “Positive” = 2 word recall and/or abnormal clock

Question 41

Potentially Reversible Dementias

• _____ Toxicity
• M______ Disturbance
• Normal Pressure _______
• _____ Lesion (Tumor, Chronic Subdural- often the pt that abuses drugs/alcohol and falls)
• Infectious Process (Me______, S_______)
• C________- Vascular Disease (S_ _ , Sarcoid)
• En______ Disorder (Thyroid, Parathyroid)
• N_______ Disease (B12, thiamine, folate)
• Other (COPD, CHG, Liver Dz check ammonia lvls, Apnea)

Answer 41

• Drug Toxicity
• Metabolic Disturbance
• Normal Pressure Hydrocephalus
• Mass Lesion (Tumor, Chronic Subdural- often the pt that abuses drugs/alcohol and falls)
• Infectious Process (Meningitis, Syphilis)
• Collagen- Vascular Disease (SLE, Sarcoid)
• Endocrine Disorder (Thyroid, Parathyroid)
• Nutritional Disease (B12, thiamine, folate)
• Other (COPD, CHG, Liver Dz check ammonia lvls, Apnea)

Question 42

Cognitive Decline

What is CJD?

Answer 42

Creutzfeldt-Jakob disease (prion disease that is asctd with mad cow disease (eating bad meat) - outcome is usually poor, has a rapid decline)

Question 43

Types of Dementia

Answer 43

Types of Dementia

Question 44

Labs for Dementia Workup

• E________
• C_ _
• ______ Enzymes
• (1) hormone
• V ____ level
• S______?
• Others only if clinical suspicion high
• Possible L _

Answer 44

• Electrolytes
• CBC
• Liver Enzymes
• TSH
• B12 level
• Syphilis?
• Others only if clinical suspicion high
• Possible LP

Question 45

Imaging

• Most Treatment Guidelines call for _______
• (1) usually adequate (w/o contrast)
• (1) if Vascular Dementia is suspected

Answer 45

• Most Treatment Guidelines call for Imaging
• CT usually adequate (w/o contrast)
• MRI if Vascular Dementia is suspected ***MRI W/O contrast is first choice - however if pt has agitation, paranoia, underlying breathing problem, MRI may not be first choice or may require sedation however sedation or contrast requires collaboration

Question 46

Why Properly Diagnose?

• There may be a readily _______ cause
• Some degenerative dementias do have symptomatic pharmacotherapies
• Patients and ________ want to know and understand what they are dealing with
• Helps _____ term planning
• Facilitates re_____ efforts
• Facilitates advocacy/______ group participation (can call ____)

Answer 46

• There may be a readily treatable cause
• Some degenerative dementias do have symptomatic pharmacotherapies
• Patients and families want to know and understand what they are dealing with
• Helps long term planning
• Facilitates research efforts
• Facilitates advocacy/support group participation (can call 311)

Question 47

Drugs that Delay Clinical Decline

(1)

Drugs in this category may delay clinical decline with benefits to both (1) and (1) in people living with Alzheimer’s disease

Answer 47

Aducanumab (Aduhelm™)

benefits both cognition and function

Question 48

Aducanumab (Aduhelm™)

MOA

Route, Frequency

• Beta Amyloid plaques disrupt _______ between _____ cells in the brain and may also activate ______ system cells that trigger _______ and ______ disabled nerve cells

Answer 48

Anti-amyloid antibody that targets beta-amyloid protein that forms in the brain and accumulates into plaques

IV infusion Q4 weeks

• Beta Amyloid plaques disrupt communication between nerve cells in the brain and may also activate immune system cells that trigger inflammation and devour disabled nerve cells
• $4500 per infusion, 60k/year, most insurances are covering this, you won’t be prescribing it but may have a pt on this and your notes will be reviewed by insurance (labs, screening) to see if they are covered*

Question 49

Drugs that may treat Cognitive symptoms (memory and thinking)

Rx (1)-(3)

MOA

Treats what symptoms?

Answer 49

Cholinesterase inhibitors

Donepezil (Aricept®)

Rivastigmine (Exelon®)

Galantamine (Razadyne®)

• These medications prevent the breakdown of acetylcholine, a chemical messenger important for memory and learning. These drugs support communication between nerve cells.
• Treat symptoms related to memory, thinking, language, judgment and other thought processes.

Question 50

Cholinesterase Inhibitors Indications

1. Donezepil (Aricept) =
2. Rivastigmine (Exelon®) =
3. Galantamine (Razadyne®) =

Answer 50

1. approved to treat all stages of Alzheimer’s disease
2. approved for mild-to-moderate Alzheimer’s as well as mild-to-moderate dementia associated with Parkinson’s disease
3. approved for mild-to moderate stages of Alzheimer’s disease

Question 51

Cholinesterase Inhibitors SE

(4)

Answer 51

Nausea, Vomiting (check K levels)

Loss of appetite (check albumin?)

Increased frequency of bowel movements

Question 52

Cholinergic Hypothesis

1. Cholinergic deficiency contributes to the (1) of AD
2. May contribute to behavior symptoms such as (4)

Answer 52

1. Cognitive decline
2. Behavior symptoms
   
   1. Psychosis-agitation
   2. Apathy-indifference
   3. Disinhibition
   4. Aberrant motor behavior

Question 53

Glutamate Regulators

Rx (1)

MOA

Indications

SE

Answer 53

Memantine (Namenda)

Regulates the activity of glutamate, a different chemical messenger that helps the brain process information

Improves memory, attention, reason, language and the ability to perform simple tasks.

Headache, Constipation, Confusion and Dizziness.

Question 54

Cholinesterase inhibitor + glutamate regulator

Rx (1)

Indication

SE

Answer 54

Namzaric (Memantine + Donezepil)

Approved for moderate-to severe Alzheimer’s disease.

Nausea, vomiting, loss of appetite, increased frequency of bowel movements, headache, constipation, confusion and dizziness

Question 55

Suvorexant Belsomra®

Indication

SE

Answer 55

Insomnia in people living with mild to moderate Alzheimer’s disease

Impaired alertness and motor coordination, worsening of depression or suicidal thinking, complex sleep behaviors, sleep paralysis, compromised respiratory function

With all of these medications - focus on the SE!

Question 56

Common Doses

1. Donezepil
2. Galantamine
3. Rivastigmine
4. Memantine

Answer 56

1. 5mg/day, 10mg/day target dose after 1m
2. 4mg BID, 24mg/day target dose, increase by 4mg BID every 1m
3. 1.5mg BID, 6-12mg target dose, increase by 1.5 BID every 1m
4. 5mg/day, 10mg BID target dose, increase by 5mg daily every week

Question 57

Dementia Interventions

• Good assessment of ____/______ situation
• _______ techniques first
• Psych meds should be start ____ and go ____ and _____ choice — C______/C_______

Answer 57

• Good assessment of home/institution situation
• Behavioral techniques first
• Psych meds should be start low and good slow and last choice — CONSULT/COLLABORATE

Question 58

Implementing Effective Interventions

• ______ Issues:
  
  • Patients may mis_______ their surroundings and become f______ of what is happening around them
  • Physical and psychological ________ safety is a priority
• E_______ Management
• M_______ Management
• _______ Stress:
  
  • Providing care for a family member with dementia can be highly stressful and overwhelming
  • Family caregivers need to receive adequate preparation and support when caring for the individual

Answer 58

• Safety Issues:
  
  • Patients may misinterpret their surroundings and become fearful of what is happening around them
  • Physical and psychological environmental safety is a priority
• Environmental Management
• Medication Management
• Caregiver Stress:
  
  • Providing care for a family member with dementia can be highly stressful and overwhelming
  • Family caregivers need to receive adequate preparation and support when caring for the individual

Question 59

Behavioral Treatment

(6)

Answer 59

• Refer to Adult Day Care
• Respite/Adult Family Homes
• Caregiver Support Groups
• Psychoeducation
• Depression in caregiver
• SNF before crisis

Question 60

Next Steps: Prepare for Chronic Care

• ________ philosophy from d______ to d______, since dementia is a…
  
  • Pr______ indicator
  • R_____ indicator
  • Ave life expectancy -_ years
• Care is ______-specific
  
  • Components of palliation vary over time
• Care is always a c________
  
  • You, the patient, and the family
  • A medical _______ specialist, when needed
  • A p________ care manager, especially at moderate dementia stages and beyond, or when families are stressed

Answer 60

• Palliative philosophy from diagnosis to death, since dementia is a…
  
  • Prognostic indicator
  • Risk indicator
  • Ave life expectancy 4.8-10 years
• Care is stage-specific
  
  • Components of palliation vary over time
• Care is always a collaboration
  
  • You, the patient, and the family
  • A medical dementia specialist, when needed
  • A psychosocial care manager, especially at moderate dementia stages and beyond, or when families are stressed

Question 61

Diagnosing Dementia and Clarifying Goals of Care

Answer 61

Question 62

Fast Scoring Dementia

Scale (1)

Answer 62

Functional Assessment Scale (FAST)

Question 63

Consult/Collaborate

• ______ onset (
• Presentation is ______
• If severe _____sonism, f_____ findings, or abnormal _____
• Behaviors seemingly “un______”
• To better document severity, consider n__________

Answer 63

• Early onset (<60)
• Presentation is atypical
• If severe parkinsonism, focal findings, or abnormal scan
• Behaviors seemingly “untreatable”
• To better document severity, consider neuropsychologist

Question 64

What is Delirium?

1. Onset
2. Duration
3. Course
4. Impaired (2)
5. (2) presentations
6. Cannot be explained by?
7. Reversibility

Answer 64

1. Acute
2. Hours-Days
3. Consciousness level fluctuates over the course of the day
4. Reduced clarity in patient’s awareness of the environment, with impaired ability to focus, sustain, or shift attention
5. The patient may be agitated, irritable, and emotionally labile or drowsy, quiet, and withdrawn
6. Cannot be explained by a patient’s preexisting, established, or evolving dementia.
7. Delirium is conceptualized as a reversible illness, except in the last 24 to 48 hours of life

Question 65

Delirium Prevalence

• 1/__ of general medical patients who are ___ years of age or older have delirium.
• Delirium is the most common ______ complication among older adults, with an incidence of 15-25% after major (1) surgery and 50% after high-risk procedures such as (2).
• Among patients undergoing (1) in ICU, the cumulative incidence of delirium, when combined with stupor and coma, exceeds 75%.
• Delirium is present in 10-15% of older adults in the (1).
• The prevalence of delirium at the end of life approaches 85% in _______ care settings.
• Delirium in a primary care setting needs?*

Answer 65

• 1/3 of general medical patients who are 70 years of age or older have delirium.
• Delirium is the most common surgical complication among older adults, with an incidence of 15-25% after major elective surgery and 50% after high-risk procedures such as hip-fracture repair and cardiac surgery.
• Among patients undergoing mechanical ventilation in ICU, the cumulative incidence of delirium, when combined with stupor and coma, exceeds 75%.
• Delirium is present in 10-15% of older adults in ED.
• The prevalence of delirium at the end of life approaches 85% in palliative care settings.
• Delirium in a primary care setting needs an ACUTE EVAL, hospital home, ER, or inpatient

Question 66

Hyperactive vs. Hypoactive Delirium

1. Which type represents only 25% of cases, describe it?
2. Which type has a poorer prognosis, why?

Answer 66

1. Hyperactive delirium, described as agitated with the others having hypoactive (“quiet”) delirium.
2. Hypoactive delirium is associated with a poorer prognosis, potentially because it is less frequently recognized. (higher risk of infection, immobility, skin breakdown)

Question 67

Hyperactive vs. Hypoactive Delirium Chart

Answer 67

Fill in the blanks

Question 68

Predisposing factors for Delirium

• _____ age
• D______ (often not recognized clinically)
• F_____ disabilities
• ____ sex
• Poor (2) senses
• D______ symptoms
• Mild ______ impairment
• A_____ abuse

Answer 68

• Older age
• Dementia (often not recognized clinically)
• Functional disabilities
• Male sex
• Poor vision and hearing
• Depressive symptoms
• Mild cognitive impairment
• Alcohol abuse

Question 69

Precipitating Factors of Delirium

• Drugs (especially sedative (2))
• S______/An_____
• High _____ levels
• An_____
• In_______
• Acute (1) or (1)
• R_______ could be an etiologic factor or a proxy for severity

Answer 69

• Drugs (especially sedative hypnotic agents and anticholinergic agents) ▪
• Surgery/anesthesia
• High pain levels
• Anemia
• Infections
• Acute illness, or acute exacerbation of chronic illness
• Restraints could be an etiologic factor or a proxy for severity

Question 70

Delirium History Cont.

• Other symptoms Ie (2), (1) weakness
• A thorough ______ review is required for all patients with delirium
• Consumption of (1) and the use of (1) drugs, dietary supplements

Answer 70

• Other symptoms(e.g., dyspnea and dysuria), focal weakness
• A thorough medication review is required for all patients with delirium
• Consumption of alcohol and the use of nonprescription drugs, dietary supplements

Question 71

Beers Criteria

High Risk Drugs in Delirium

(11)

BONAAAATHAB

Answer 71

1. Benzodiazepines
2. Opioid analgesics (especially meperidine)
3. Nonbenzodiazepine sedative hypnotics (ie zolpidem)
4. Antihistamine (1st gen sedating agents doxylamine and diphenhydramine)
5. Alcohol
6. Anticholinergics (oxybutynin, benztropine)
7. Anticonvulsants (primidone, phenobarbital, barbital, phenytoin)
8. Tricyclic antidepressants (especially tertiary amines - amitriptyline, imipramine, doxepin)
9. Histamine H2 receptor blockers
10. Antipsychotics (especially low potency typical antipsychotics like chlorpromazine and thioridazine)
11. Barbiturates

Question 72

Delirium

• The first step in delirium management is accurate _____ using (1)
• After receiving a diagnosis of delirium, patients require a thorough evaluation for ______ causes all correctable contributing factors should be addressed.

Answer 72

• The first step in delirium management is accurate diagnosis; a brief validated instrument that assesses features in the Confusion Assessment Method algorithm is recommended.
• After receiving a diagnosis of delirium, patients require a thorough evaluation for reversible causes; all correctable contributing factors should be addressed.

Question 73

CAM Diagnostic

• Only ___-___% of delirium cases are recognized.
• Systematic reviews support the (1) as the most useful bedside assessment tool.
• The CAM algorithm establishes the diagnosis of delirium according to the presence or absence of (4) features

Answer 73

• Only 12 to 35% of delirium cases are recognized.
• Systematic reviews support the Confusion Assessment Method (CAM) as the most useful bedside assessment tool.
• The CAM algorithm establishes the diagnosis of delirium according to the presence or absence of four features:
  
  1. acute change in mental status with a fluctuating course
  2. inattention, and either
  3. disorganized thinking or an
  4. altered level of consciousness.

Question 74

Differential Diagnosis for Delirium

• (3)* should all be considered in the differential diagnosis for delirium. These syndromes often co-occur, patients may have more than one.
• In the absence of clear documentation from medical records or reports from family members that the patient’s mental status is consistent with his or her baseline, it is always safest to?.
• Reports of an ____ change in _____ status, witnessed ______ over a period of minutes to hours, or an abnormal level of _______ fulfill CAM criteria and make delirium more likely.

Answer 74

• Dementia, depression, and acute psychiatric syndromes(mania) should all be considered in the differential diagnosis for delirium.These syndromes often co-occur, patients may have more than one.
• In the absence of clear documentation from medical records or reports from family members that the patient’s mental status is consistent with his or her baseline, it is always safest to assume delirium.
• Reports of an acute change in mental status, witnessed fluctuations over a period of minutes to hours, or an abnormal level of consciousness fulfill CAM criteria and make delirium more likely.

Question 75

Causes of Delirium

• D
• E
• L
• I
• R
• I
• U
• M

Answer 75

• D: Drugs (opioids, anticholinergics, sedatives, steroids, benzodiazepines, chemotherapy and immunotherapies, some antibiotics)
• E: Eyes and ears (poor vision and hearing, isolation)
• L: Low flow states (hypoxia, MI, HF, COPD, shock)
• I: Infections
• R: Retention (urine/stool), restraints
• I: Intracranial (CNS metastases, seizures, subdural, CVA, hypertensive encephalopathy)
• U: Underhydration, undernutrition, undersleep
• M: Metabolic disorders (sodium, glucose, thyroid, hepatic, deficiencies of vitamin B12, folate, niacin, and thiamine) and toxic (lead, manganese, mercury, alcohol)

Question 76

Labs for Delirium

• C___, B___, ____FTs, ___SH and C_/S, Vitamin __
• Tests that are routinely required include a (2)
• Chest _____, and ____ are also often helpful
• Additional tests that are useful in select situations include
  
  • blood and urine ______studies,
  • blood _____,
  • (1) (if hypercapnia is suspected)
  • (1) (in patients with head trauma or new focal neurologic findings)
  • (1) (if findings suggest meningitis or encephalitis)
  • (1) (if seizures are suspected)

Answer 76

• CBC, BMP, LFTS, TSH, UA and C/S Vitamin B12
• Tests that are routinely required include a CBC and BMP
• Chest radiography, and EKG are also often helpful
• Additional tests that are useful in select situations include
  
  • blood and urine toxicology studies
  • blood cultures, ABG (if hypercapnia is suspected)
  • cerebral imaging (in patients with head trauma or new focal neurologic findings)
  • LP (if findings suggest meningitis or encephalitis)
  • EEG (if seizures are suspected)

Question 77

Medications for Delirium

(6)

Answer 77

Haloperidol

Risperidone

Olanzapine

Quetiapine

Ziprasidone

Lorazepam

Question 78

Delirium Key Points

• Is patient with delirium dis______ or are a ____ to themselves or others:
  
  • Avoid drugs with anti______activity, is associated with worsening delirium.
  • For hypoactive delirium, especially where agitation is not overt and delirium may not be recognized, _____ dosing is recommended.
  • OUTPATIENT NEEDS _____

Answer 78

• Is patient with delirium distressed or are a risk to themselves or others:
  
  • Avoid drugs with anticholinergic activity. Anticholinergic activity is associated with worsening delirium.
  • For hypoactive delirium, especially where agitation is not overt and delirium may not be recognized, scheduled dosing is recommended.
  • OUTPATIENT NEEDS EVAL