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Dementia or Delirium or Depression

Dementia or Delirium or Depression. Dr Nick Bretland Canning Division of General Practice. What is Dementia?. Sustained reduction of previously established mental abilities Involves several areas of cognition Clear consciousness Causes functional problems. Types of Dementia.

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Dementia or Delirium or Depression

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  1. Dementia or Delirium or Depression Dr Nick Bretland Canning Division of General Practice

  2. What is Dementia? • Sustained reduction of previously established mental abilities • Involves several areas of cognition • Clear consciousness • Causes functional problems

  3. Types of Dementia • Alzheimer’s Dementia • Vascular Dementia • Frontal Lobe Dementia • Lewy Body Dementia

  4. Alzheimer’s Dementia • Slowly Progressive • Earliest Loss is Recent Memory • Often preceded by Depression • Progressive decline in intellect • Progressive loss of functional abilities • Neurological losses

  5. Vascular Dementia • Multi-infarct (usually embolic) • Small vessel infarct (disconnects frontal lobes) • Picks off individual executive functions • Often combined with Alzheimer’s Dementia • Neurological symptoms

  6. Periventricular White Matter Loss

  7. Frontal Lobe Dementia • Specific loss of Frontal Lobe tissue • Main losses • Recent Memory • Language • Executive function • Personality change • Behaviour • Depression • Hallucinations • Neurological Symptoms

  8. Frontal Lobe Atrophy

  9. Lewy 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

  10. Symptoms 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

  11. Delirium 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

  12. DSM 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

  13. Subtypes of Delirium • Hyperactive Picking at bedclothes Tapping fingers, Agitation • Hypoactive Lying passive in bed ( O sign) • Mixed • Prodromal

  14. INFECTION Hypoxia Hypoglycaemia Hyperthermia Drugs (esp anticholinergics) Withdrawal (alcohol and sedatives) PAIN Metabolic Vitamin deficiency Urinary retention Constipation Sensory deprivation Heart, liver, renal failure Causes of Delirium

  15. On 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

  16. Warning 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

  17. Prevention • 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

  18. Management • Identify Cause • History • Examination • Investigations • Rating Scales • Clock Face • CAM • Delirium Rating Scale

  19. Clockface Test

  20. Treatment • 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

  21. Treatment • 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

  22. Best 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”

  23. Is It Delerium?

  24. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ageing-delirium.htm~ageing-delirium05.htmhttp://www.health.gov.au/internet/wcms/publishing.nsf/Content/ageing-delirium.htm~ageing-delirium05.htm http://www.health.gov.au/internet/wcms/publishing.nsf/Content/9E46460CFDAFBA03CA25732B004C4331/$File/Prevention.pdf

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