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Dementia and Delirium

by John Burton, M.D.

Introduction
Dementia is a progressive decline in memory and at least one other cognitive area in an alert person.  These cognitive areas include attention, orientation, judgment, abstract thinking and personality.  Dementia is rare in under 50 years of age and the incidence increases with age; 8% in >65 and 30% in >85 years of age.

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Causes and Risk Factors
There are several risk factors for dementia:

  • Age
  • Down’s Syndrome
  • Head injury
  • Fewer years of education
  • Female
  • Genetics
    * Early onset of mutations in chromosome 1, 14, and 21
    * Late onset of mutations in chromosome 19
         -apolipoprotein E gen (APOE 2, 3, and 4)
         4/4 greatest risk (3% of population)
         3/4 next risk (20% of population)
         2 may be protective
     APOE 4 neither necessary nor sufficient to cause dementia
    * Genetic screening is not recommended

Dementia results from brain damage.  The causes include the following; Alzheimer’s Disease, Stroke, Pick’s disease, Huntington’s, Downs Syndrome, Creutzfeldt-Jacob, AIDS, alcoholism, Parkinson’s disease and other neurodegenerations.

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Diagnosis
There are three purposes why diagnosing dementia is essential. 

  1. By determining the probable cause, treatable disorders can be identified, such as medication toxicity (benzos, H2 blockers and anticholinergics), and thyroid disease.
  2. There are symptoms and comorbidities that are treatable, such as depression, delirium (see below), delusions, hallucinations, and agitation.
  3. Caregivers must be identified and environmental issues taken into consideration.

A diagnosis of dementia is based on:
memory loss - both in short and long-term, plus one or more of the following:

  • aphasia – language problems
  • apraxia – organizational problems
  • agnosia – unable to recognize objects or tell their purpose
  • disturbed executive function – personality and inhibition

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Assessment
An assessment for dementia may include the following:

  • History, both from the patient and close observers
  • Focused physical
  • Mini Mental State Exam
  • Lab work including CBC, basic metabolic profile, TSH, Vitamin B12, STS
  • If brain injury or space occupying lesion such as a tumor is in question, CT, or  MRI.
PET scans are occassionally recommended in the early diagnosis of dementia although there remains some controversy as to precisely their indication and value

Additionally, depression, delirium (discussed below), agitation, hallucinations, and delusions are important comorbidities that must be taken into consideration.  Behavorial issues may require a referral to a specialist.

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Treatment
There are both pharmacologic and non-pharmacologic interventions that may be beneficial for patients with dementia.

Non-pharmacologic Interventions 

  • Social activities
  • Adequate sleep
  • Adherence to a strict schedule
  • Maintenance of a proper stimulation level
  • Adequate hydration
  • Reformatting task (occupation therapy)
  • Support caregivers

Pharmacologic Interventions (course is typically 10 years, but 2-20 possible)

  • Prevention
          * Vitamin E, and cognitive stimulation such as education
  • Memory/attention
  • Acetylcholinesterase Inhibitors
          * Tacrine
          * Donepezil hydrochloride
          * Rivastigmine tartrate
          * Galantamine hydrochloride
  • NMDA antagonists
          * Memantine
          * Others (Ginkgo biloba, caffeine, nicotine, methylphenidate, NSAIDs)
  • Behavioral 
          * Antipsychotics
          * Antidepressants
          * Mood stabililizers

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Dementia vs Delirium
In order to make a diagnosis of dementia, delirium must be ruled out.  However, patients with dementia are at increased risk of delirium and may have both.  Delirium is an acute disorder of attention and global cognition (memory and perception) and is treatable.  The diagnosis is missed in more than 50% of cases.  The risk factors for delirium include age, pre-existing brain disease, and medications.  There are many causes, the most common are:

   D   Dementia
     Electrolyte disorders
     Lung, liver, heart, kidney, brain
   I    Infection
   R   Rx Drugs
   I    Injury, Pain, Stress
   U   Unfamiliar enviroment
   M   Metobolic

Prevention of delirium includes the avoidance of psychoactive drugs, quiet environment, daytime activity, dark and quiet at night, visual and hearing assistive devices, orientation devices, and avoidance of restraints.

Diagnosis of delirium is based on clinical observation; no diagnostic tests are available.  The essestial features of delirium include:

  • Acute onset (hours/days) and a fluctuating course
  • Inattention or distraction
  • Disorganized thinking or a altered level of consciousness

Treatment of delirium, like dementia, is managed both pharmacologically and non-pharmacologically.

Non-pharmacologic management

  • Optimize environment
  • Personal belonging – photographs
  • Quiet
  • Sitter

 Pharmacologic management

  • Neuroleptics may be needed if the patient is having distressing hallucinations/delusions or 
      
    the patient is very agitated
  • High potency with low anticholinergic activity
  • Low dose
  • Haloperidol or risperdone
  • Benzodiazepine if delirium is secondary to benzo or alcohol withdrawal

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References

Clin Geriatr Med 20 (2004) March
Ann Intern Med 2004: 140; 501.

Visit the Mental Health Association of Maryland for additional information and assistance.

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