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n Dementia or Delirium or Depression

Dr Nick Bretland

Canning Division of General Practice

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nWhat is Dementia?

• Sustained reduction of previously established mental abilities

• Involves several areas of cognition

• Clear consciousness

• Causes functional problems

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nTypes of Dementia

• Alzheimer’s Dementia

• Vascular Dementia

• Frontal Lobe Dementia

• Lewy Body Dementia

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nAlzheimer’s Dementia

• Slowly Progressive

• Earliest Loss is Recent Memory

• Often preceded by Depression

• Progressive decline in intellect

• Progressive loss of functional abilities

• Neurological losses

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nVascular Dementia

• Multi-infarct (usually embolic)• Small vessel infarct (disconnects

frontal lobes)• Picks off individual executive

functions• Often combined with Alzheimer’s

Dementia• Neurological symptoms

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nPeriventricular White Matter Loss

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nFrontal Lobe Dementia

• Specific loss of Frontal Lobe tissue• Main losses

– Recent Memory– Language– Executive function– Personality change

• Behaviour• Depression• Hallucinations

– Neurological Symptoms

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nFrontal Lobe Atrophy

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nLewy Body Dementia

• Variable levels of cognitive loss from day to day

• Parkinsonian features– Tremor– Shuffling Gait– Instability

• Prominent hallucinations– Well formed– Often people– Not frightening

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nSymptoms of Depression

• Depressed Mood• Loss of interest or pleasure• Significant appetite or weight loss or gain• Poor sleep or excess sleep• Psychomotor retardation or agitation• Fatigue or loss of energy• Feeling worthless or guilt• Poor thinking and concentration• Suicidal thoughts

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nDelirium

Transient Global Disorder of Cognition

• Affects 20-40% hospital admissions• Occurs in 80% of terminal illness• Mortality 10-26%• Prolongs Hospital Stay by 7 days• 25-50% have underlying dementia

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nDSM IV Criteria

• Disturbed Consciousness– Reduced clarity of awareness of environment

– Reduced ability to focus or shift attention

• Change in Cognition– Memory deficit

– Language or perceptual disturbance

• Development over a short period of time and fluctuates through the day

• History, Examination and Laboratory findings indicate direct physiological consequences of a medical condition

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nSubtypes of Delirium

1. HyperactivePicking at bedclothesTapping fingers,Agitation

2. HypoactiveLying passive in bed ( O sign)

3. Mixed4. Prodromal

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nCauses of Delirium

• INFECTION• Hypoxia• Hypoglycaemia• Hyperthermia• Drugs (esp

anticholinergics)• Withdrawal

(alcohol and sedatives)

• PAIN• Metabolic• Vitamin deficiency• Urinary retention• Constipation• Sensory

deprivation• Heart, liver, renal

failure

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nOn the Ward

• Top risk factors– Pre-existing Cognitive Impairment– Severe Medical Illness– Age 70 or over– Visual Impairment– Depression– Abnormal Sodium levels– Indwewlling Catheter– Use of Physical Restraints– Medications: Pethidine, BZD, Alcohol

withdrawal

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nWarning Signs!

• High Index of Suspicion• Sudden onset of abnormal behaviour is more likely

to be delirium than dementia• Hallucinations are more likely to be due to

delirium than psychiatric illness• Sleep/Wake Cycle Reversal• Beware the Hypoactive Patient• Multiple medicines• Indwelling Catheters• Avoid physical restraints• Treat it as a medical presentation

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nPrevention

• Environmental– Lighting appropriate to time of day– Single Room– Quiet – Clock and Calender– Family and Carer involvement– Familiar objects in Room

• Clinical– Assist with Eating and drinking– Glasses and hearing aids– Avoid Constipation– Mobilise– Medication Review– Manage Pain– Promote sleep

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nManagement

• Identify Cause– History– Examination– Investigations

• Rating Scales– Clock Face– CAM– Delirium Rating Scale

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nClockface Test

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nTreatment

• Non-Pharmacological– Same as delirium prevention– One on One nursing– Validation and reality orientation– Family members to assist– Same staff – Relaxation Strategies to help sleep– NO PHYSICAL RESTRAINTS

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nTreatment

• Medical– Treat underlying cause

• Pharmacological– SEVERE BEHAVIOURAL DISTURBANCE

ONLY – Antipsychotic meds (Haloperidol)– Second Generation Antipsychotics (Zyprexa,

Risperidone etc)– Low dose– Titrate up and review regularly

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nBest Practice

• On Admission: – Baseline cognitive function (MMSE or AMT)

• Repeat assessment – day 6 and week 6– High risk cases may need daily assessment– sudden change in behaviour or cognition

• If Delirium Suspected – (MMSE declines by 2 or more points)– Formal assessment with diagnostic tool– Refer to “delirium expert”

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nIs It Delerium?Delerium Dementia Depression

Onset Acute Insidious Variable

Course Fluctuating Steadily Progressive

Diurnal Variation

Consciousness & Orientation

Clouded & disorientated

Clear until late stages

Generally unimpaired

Attention & Memory

Poor short term memory. Inattention

Poor short term memory. No Inattention

Memory intact Poor attention

Psychosis Common (fleeting ideas with simple content)

Less common Uncommon (complex ideas with congruent mood)

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http://www.health.gov.au/internet/wcms/publishing.nsf/Content/

9E46460CFDAFBA03CA25732B004C4331/$File/Prevention.pdf

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ageing-

delirium.htm~ageing-delirium05.htm