Dementia vs Delirium Flashcards
Define dementia
Major neurocog disorder
- acquired disorder characterized by decline in cognition involving 1+ cognitive domains
Define mild cognitive impairment
Mild neurocog disorder
- state between normal cognition and dementia where functional abilities are preserved, but can be a precursor to dementia
Define delirium
- problem with attention, awareness, develops over short period of time
- triggered by wide variety of chonditions
- days to months long
Define encephalopathy
medical diagnosis characterized by symptoms of delirium, confusion, AMS, secondary to many things like stroke, hypoglycemia, seizure, infection, substances, etc. (ie: septic encephalopathy from a UTI)
Describe the 5 key features of delirium in the DSM 5
- disturbance in attention and awareness
- short period of time
- additional cognitive disturbances
- not explained by established/evolving neurocog disorder
- evidence that it is secondary to a physiologic consequence
Explain the consequences of delirium
- increases risk of death within a month
- length of hospital stay doubled
- increased risk of complications
- increased risk of dementia
- 2x risk of RN home need
Describe the pathophys of delirium
- systemic trigger (inflammation, hypoxemia)
- vulnerabilities exacerbated (neuronal damage, vascular dysfunction, astrocyte/microglia degeneration)
- cause cellular and functional changes leading to neuronal dysfunction, immune cell infiltration, metabolic insufficiency
- lead to delirium
List some premorbid factors for delirium
- age
- dementia
- low education
- high comorbidity burden
- frailty
- tethers to bed
Describe hypoactive vs hyperactive delirium
How to diagnose symptoms of delirium
DSM 5 but more commonly the CAM (confusion assessment method)
CAM
- acute onset of mental status change or fluctuations and
- inattention and
- disorganized thinking or
- altered consciousness (anything other than alert)
How can delirium be prevented
through delirium prevention protocols that systemically address risk factors (ABCDEF ICU bundle)
- there are no pharm interventions that decrease risk indefinitely (pain, symptom management can help)
How to reduce risk of delirium
mitigate risk factors
How to manage delirium
- identify and reverse potential reversible triggers
- correct physiologic disturbances
- engage family and other support
- antipsychotics (olanzepine, haloperidol) off label as last resort - can exacerbate elderly with dementia or increase rate of death
How does the DSM define dementia
- significant cognitive decline in 1+ cognitive domains
- interference with ADLs
- not exclusively during delirium
- not better explained by another mh disorder
What are some of the types of dementia
- Alzheimer’s (60-80%)
- cerebrovascular disease
- frontotemporal
- dementia with lewy body
- Parkinsons
- Huntingtons
- can have mixed types
- etc.
Why is the rate of dementia increasing so much
because we are living longer
How does dementia typically present initially
- family/spouse brings problem to attention
- memory difficulties
- trouble retaining new info, complex tasks, reasoning, spatial orientation, language, behavior
- change from baseline gradual and progressive over time
Risk factors for dementia
- age
- lower education level
- rare genetic factors (APOE Chr 19)
- CV disease
- psychiatric disease
- head trauma
- heavy alc use
What are some protective factors against dementia
- higher education level
- bilingualism
- cognitively stimulating activities
- mediterranean diet
- physical activity
Describe alzheimer’s dementia
- typically 65+ (25% 85-90, 33% 90)
- memory impairment most common
- brain changes thought to start 20 years before syx
Describe the hallmark pathogenesis of alzheimer’s disease
accumulation of tau protein tangles inside neurons and beta-amyloid protein plaques outside neurons in the brain
- tau tangles block nutrients
- beta-amyloid plaques interfere with neuron communication
- results in neuronal death that is progressive and fatal
Describe the inflammatory process involved in alzheimers
tangles and plaques activate microglia which try to clear the toxic proteins and debris from dying cells
- chronic inflammation sets in when microglia can’t keep up
What are some diagnostic tests used in evaluation of alzheimer’s
- clock drawing test: would be abnormal
- PET biomarkers
Describe treatment for Alzheimer’s
- improve symptoms: Donepezil (Cholinesterase inhibitor) or Memantine (NMDA receptor agonist)
- music, memory training, lighting
What are the 5 As related to Alzheimers
Amnesia
Anomia
Apraxia
Agnosia
Aphasia
Describe vascular dementia
associated with CV small vessel ischemic disease resulting in brain tissue lacking oxygen and nutrients
- changes in executive function and processing speed
- associated with strokes
- imaging will show evidence of vascular disease
Describe Lewy body disease
Abnormal clumps of protein alpha-synuclein inside the neurons
- syx of sleep disturbance, AVH, visuospatial impairment
- often assoc. with Parkinsons
Describe frontotemporal dementia
nerve cells in frontal and temporal lobes atrophy
- early syx of personality, behavior, language comprehension change
What might be on the differential list for dementia evaluation
- neurosurgical conditions (subdural hemorrhage, brain tumors, abscess, normopressure hydrocephalus)
- inflammatory (meningitis, encephalitis, vasculitis, lyme)
- metabolic (thyroid, calcium, cushing, hypoglycemia, folate, thamine deficiency, liver, resp, CKD, Wilson)
- MH, epilepsy, substance use
Describe some cognitive screening tools helpful in diagnosing dementia
- clock drawing test
- MMSE
- Montreal Cognitive Assessment (MOCA)
- neuropsych testing (including depression)
What labs should be done in evaluating dementia
- B12, CBC, TSH
- sometimes syphilis, HIV
What imaging should be used in evaluating dementia
- always image for acute onset of cog impairment
- noncontrast head CT or MIR in routine initial eval: can show atrophy of cerebrum, hippocampus, ventriculomegaly, old ischemia)
Describe the non-pharm management of dementia
- treat CV risk factors
- review meds and avoid AEs
- nutritional eval
- exercise programs
- limit alc
- manage safety issues (driving, falls, behavior, wandering, cooking)
Describe the key differences between delirium and dementia
Describe the disease course of alzheimer’s
what is the key triad for normal pressure hydrocephalus
urine incontinence, ataxic gait, cognitive impairment
(drain some CSF to see if it gets better)
What is the new drug on the block for Alzheimer’s treatment
Aducanumab
- only in research studies
- monoclonal antibody directed against beta-amyloid plaques
- approved for mild alzheimers/mild cognitive impairment
- slows decline of alzheimers maybe, but how much plaque needs to be removed
