Educational Objectives

The goal of this program is to improve the clinical recognition of delirium and the delivery of multidisciplinary sup­port for patients with dementia. After hearing and assimilating this program, the clinician will be better able to:

1.   Assess whether patients are at high risk for delirium.

2.   Distinguish delirium from overlapping neurologic pathologies.

3.   Provide appropriate emergency care to patients presenting with altered mental status.

4.   Counsel caregivers on how to best care for patients with dementia throughout all stages of the disease.

5.   Recognize patients functioning as caregivers and provide appropriate support.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of in­terest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgments

Dr. Engstrom was recorded at Essentials of Primary Care, held August 9-14, 2009, in North Lake Tahoe, CA, and spon­sored by the University of California, San Francisco. Dr. Parks was recorded at 32nd Annual Eastern Shore Medical Sympo­sium, held June 22-26, 2009, in Rehoboth Beach, DE, and sponsored by Jefferson Medical College and the University of Delaware, with promotional assistance provided by the Medical Society of Delaware. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Declining and Altered Minds: Delirium and Dementia

Delirium and Dementia

John W. Engstrom, MD, Professor and Vice-Chair, Department of Neurology, University of California, San Francisco, School of Medicine

Delirium: ability to provide lucid history establishes normal orientation, attention, recent recall, and speech; history that suggests cognitive problem necessitates methodical mental status examination; in setting of altered mental sta­tus, signs on general examination indicate presence of delirium and differentiate sympathetic nervous system over­activity from underactivity; in delirium, acute cognitive changes occur over hours to days; fluctuating attention key indicator; may affect all aspects of cognition, including memory, language, and visuospatial testing

Diagnostic tests: memory tests unreliable after diagnosis of confused state; digit span testing  —  in young adults, av­erage recall spans 7 forward and 4 backward; forward testing typically sufficient; digit span recall declines slightly with age (80-yr-old should still recall 6 digits forward); test of recent memory  —  patients must retain information for short period (eg, recall 3 different objects 5 min later); sympathetic overactivity states  —  eg, alcohol withdrawal, hyperthyroidism, drug effect; sympathetic underactivity  —  caused by eg, sedative hypnotics; history from witnesses frequently presents conflicting information due to fluctuating nature of syndrome

Risk factors for delirium: age >65; baseline cognitive dysfunction (lowers threshold for delirium; prolongs recov­ery) establish true baseline by contacting caretakers; diminished hearing or vision; poor general health; bladder catheters (associated urinary tract infections); new medications; restraints; sleep deprivation; screen for metabolic causes and sepsis

Dementia: poor intellectual or cognitive function with no disturbance of consciousness; older patients at risk for both delirium and dementia; patients with dementia typically display social behavior and engage in basic conversation; similarities and differences  —  useful bedside test; assesses abstract thinking; eg, ask patient to explain differences and commonalities between apples and oranges; delirium impairs even basic abstract thought; cognitive functioning  —established by questioning family and friends after establishing cognitive baseline; ask about func­tional cognitive activities engaged in by patient (eg, finances); visual hallucinations  —frequently attributed to met­abolic disorders (eg, alcohol withdrawal); typically related to neurodegeneration in patients with Parkinson’s disease; Lewy body dementia  —frequently causes visual hallucinations; may account for 15% to 25% of patients di­agnosed with Parkinson’s disease; visual hallucinations increase over time; responds to carbidopa-levodopa (Sinemet), resulting in frequent misdiagnosis of Parkinson’s disease; carbidopa-levodopa causes visual hallucina­tions in absence of pathology; as neurodegeneration progresses, even low doses may trigger hallucinations; stroke and visual deficit  —  typically produces inability to see, rather than hallucinations in visual field; neurodegenerative symptoms overlap with symptoms of delirium, but persist significantly longer

Thiamine deficiency: presents with enlarged mammillary bodies on MRI; metabolic cause of delirium with highly specific treatment; frequently underrecognized; in autopsy studies, only 10% of patients accurately diagnosed be­fore death; expecting presence of all 3 major indicators (confusion, limitation of eye movements, truncal ataxia) frequently leads to missing diagnosis of thiamine deficiency; suspect when confusion of unknown cause present with malnourishment; deficiency typically impairs absorption, necessitating intravenous or intramuscular thiamine

Encephalopathy: clonus  —  typically elicited by rapid movement of joint or hyperreflexia; frequently occurs at ankle, occasionally entire leg; rhythmic and induced by movement; myoclonus  —  almost uniformly presents with asyn­chronous features (eg, twitching, but not rhythmic); ongoing seizure  —  especially with rhythmic twitching of digit or ocular deviation to one side with nystagmoid movement; dystonia  —  presents as abnormal, fixed posture (typi­cally of leg or trunk) with no rhythmic movements; postural tremor  —  fine high-frequency tremor when limb held against gravity; subsides at rest

Seizures and delirium: delirium may persist after seizure into postictal state; mimics sedative-hypnotic drug effect, but may indicate sympathetic overactivity; evaluate patient for earlier seizure; frequent subtle seizures (particularly partial-complex type) may induce prolonged postictal state; actual seizure activity often too short-lived for observa­tion; specific metabolic disorders predispose patients to both seizures and delirium (eg, severe hypoglycemia)

Receptive aphasia: patients frequently fabricate words (neologisms) or speak nonsensically; occasionally clinically indistinguishable from delirium (neuroimaging requiered to confirm diagnosis); majority of patients displaying re­ceptive aphasia present with hemiparesis or visual field cuts; screen for aphasia assesses repetition, naming, and comprehension (varies with severity of delirium); meaningful response to any questions establishes comprehen­sion, ruling out receptive aphasia

Brain injury: subdural hematoma  —  compresses brain; neurologic structures may shift across midline; in most se­vere cases, medial portion of temporal lobe extends and compresses brainstem and third cranial nerve; common in pa­tients with no history of falling; computed tomography (CT) of head recommended for patients at high risk; nonfocal neurologic examination  —  common; neurologists have difficulty predicting findings associated with compression of brain; findings may refer to hemisphere opposite subdural hematoma; early herniation  —  may present with evi­dence of partial third cranial nerve palsy (parasympathetic nerve fibers affected, producing dilated pupils); suspi­cion warranted even without pupil indications; prompt imaging required once brainstem symptoms manifest (to rule out incipient brainstem compression); coma  —patients without involvement of deep gray matter of thalamus typically maintain ability to localize painful stimulus; in absence of verbal communication, physicians may assess volitional activity by applying sternal rub; patients who reach toward sternum receive diagnosis of encephalopathic state (ie, not comatose); brainstem reflexes  —  differentiate “dense” encephalopathy from coma; pupils correspond to upper and midbrain; corneal function and “doll’s eyes” reflex correlate to middle brainstem and pons; respiration and cardiovascular function correlate to lower brainstem; mid-position fixed pupils  —  typically indicates late herni­ation compromising both sympathetic and parasympathetic nerves in brainstem

Altered mental status: general examination  —  should focus on distinguishing delirium from alternative diagnosis; look for tachycardia, fever, stiff neck, tremor, asterixis, or myo-clonus (common accompaniments of delirium or encephalopathy); patients with limited functioning may retain ability to track face or finger; horizontal nystagmus frequently indicates metabolic disorder; nystagmus in vertical plane typically indicates structural pathology (most often in posterior fossa; requires immediate imaging); measure sensory function and withdrawal on both sides of body (eg, with painful stimulus to nail beds); facial response to painful stimulus may reveal asymmetry ; motor examination  —patients typically uncooperative; check limb movement against gravity; attempt to get patient walk­ing or standing; destructive processes in cerebellum (eg, hemorrhage) may selectively interfere with ability to sit or stand (no changes in limb coordination); making patient sit and stand allows assessment for midline cerebellar find­ings; cerebrospinal fluid (CSF) examination  —  underutilized; screens for infectious meningitis (acute and chronic) recommended with even slightest suspicion; indicated in unexplained delirium after imaging fails; assessment for xanthochromia critical; bleeding into subarachnoid space produces chemical meningitis and delirium; blood fre­quently not visible (depends on when hemorrhage occurred); rule of halves  —xanthochromia appears 0.5 day after hemorrhage, peaks at 0.5 wk, begins to disappear after 0.5 mo; meningitis  —neoplastic meningitis typically accom­panied by other systemic signs of advanced neoplasm; other types include chemical meningitis; patient may display evidence of vasculitis, sarcoidosis, or other uncommon disorders; HIV encephalopathy  —  causes impaired atten­tion, forgetfulness, and white matter lesions; other sources of CNS involvement require exclusion; herpes simplex encephalitis  —  may present with only confusional state and abnormal behavior (due to temporal lobe involvement); indicated by fever, headache, and focal findings; patients with abnormal CSF (pleocytosis and elevated protein in polymerase chain reaction) typically receive acyclovir

Types of dementia: Alzheimer disease  —  recent memory loss prevalent, but attention span typically preserved; in mild cases, patients recall forward digit spans of 6 to 7; vascular dementia  —  fairly common; occurs with extensive vascular disease and shows extensive vascular changes on neuroimaging; frontotemporal dementias  —  produce changes in behavior and anxiety; patients typically perform well on mental status examinations but exhibit deeper cognitive changes

Consequences of Dementia

Susan M. Parks, MD, Associate Professor, Department of Family and Community Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA

Background: speaker explains dementia to families as umbrella term for difficulties with memory and thinking; statistics  —  dementia of Alzheimer disease most common type (60%-80%); vascular dementia (related to stroke) second most common; frontotemporal dementia  —  emerging prevalence; associated with early personality and be­havioral changes; life expectancy estimates  —  all forms of dementia terminal; Alzheimer disease (4-6 yr); vascular dementia (»3 yr); frontotemporal dementia (3-10 yr); societal impact  —  5% of population >70 yr of age and 50% of population >90 yr of age develop Alzheimer disease; 24 million with dementia by 2001 estimates (number ex­pected to double by 2025); nonprofessional caregivers  —  27.6 million caregivers providing »$196 billion in care annually; spouses (70%); children (20%); other relatives (10%); majority women; speaker recommends explaining illness (eg, to family) during diagnostic process while avoiding overabundance of information; value of informing patient about diagnosis debated; speaker typically includes patient only in initial discussion (after permission from family); trajectory of illness communicated gradually; mini-mental state examination (MMSE)  —  patients with mild dementia score ³20; moderate dementia (10-20); severe dementia (<10)

Driving safety: older individuals estimated to comprise 25% of drivers by 2030; responsible for 7% of accidents, but 15% of traffic fatalities; mixed evidence associates mild cognitive impairment and mild dementia with increased crash rates; dementia inevitably affects driving safety; physicians must assess for increased safety risks; loss of driver’s license significant and affects quality of life (associated with poorer health and depression); several states make reporting mandatory; assessing driver safety  —document driver history; ask about recent accidents and tick­ets, getting lost, frequency of driving, and self-limiting behavior (eg, driving only for specific purposes); objective second individual should be asked about driving safety (in private); American Medical Association guide  —  assesses vision, motor function, and cognition; includes visual acuity testing, rapid walking, and range of motion test (ie, ability to look over shoulder); cognitive tests include trails B and clock draw; clock draw  —  patient asked to draw clock face on blank paper and illustrate time using both hemispheres; trails tests  —  assess executive function­ing; trails A involves connecting series of numbers in order; trails B connects interspersed letters and numbers (high difficulty); American Academy of Neurology review (2000)  —evidence-based review of Alzheimer disease and driving risk; recommended patients with MMSE <20 not drive; studies correlate scores <20 with worse driving ability; absolute cutoff score not defined; MMSE scoring combined with results from clock draw and trails tests be­fore making decision; behind-the-wheel testing  —  gold standard; typically administered by driving rehabilitation specialist; usually not covered by insurance (costs $200); state mandatory reporting laws  —  physicians immune from litigation in these states

Increased supervision: independent activities of daily living (IADL)  —  primary focus when assessing increased need for supervision; includes complex tasks (eg, shopping, paying bills, personal grooming, housekeeping); financial activities typically impaired first; ask about ability to handle checkbook; activities of daily living (ADLs)  —  include eating, dressing, toileting, and transferring; safety of independent living  —  determined on case-by-case basis; need for assistance with ³ 1 core ADLs typically necessitates 24-hr supervision (not absolute); physicians should ask family members about home accidents (eg, items left unattended on stove) and wandering behavior; caregiving  —  informal care provided by family members and friends; caregivers require multidisciplinary support, including health care providers, social workers, home care workers, and clergy; physicians frequently unaware of patients in caregiving role; study found 24% of patients who see family physicians were caregivers; associated with high inci­dence of depression (30%-60%) and anxiety (17%); caregivers rate personal health status significantly lower than controls; overall mortality risk among elderly spousal caregivers expressing burden or stress rises by 63% (vs con­trols); 20% of caregivers forced to leave jobs; 31% of families reported losing all or most of savings due to patient’s illness; assisting caregivers  —  recognition of patients in caregiving role critical; provide disease-based education; watch for common associated health effects (eg, depression); offer links to community resources; provide refer­rals for bereavement counseling when necessary; community resources  —include home care, senior centers, and adult day programs; day programs geared toward dementia and provide respite for caregivers; Alzheimer’s Associ­ation and Area Agency on Aging provide online locators of respite care; national registries for dementia link with local police departments to provide alerts for lost patients

Advanced stages: all patients with dementia eventually have difficulty eating; pocketing food  —  behavior caused by apraxia; speaker recommends preparing caregivers for inevitable feeding issues and providing information about behavioral indicators; helpful feeding techniques  —increased feeding assistance; stable and upright feeding posi­tion; smaller portions (on plate and fork); softening food (eg, with gravy); feeding tubes  —  multiple studies show no benefit for advanced dementia; associated with chronic diarrhea, dislodgment problems, discomfort, increased risk for aspiration pneumonia, and increased use of restraints; no measurable increases in survival found

Suggested Reading

Aarsland D et al: Frequency and case identification of dementia with Lewy bodies using the revised consensus criteria. Dementia and Geriatric Cognitive Disorders 26:445, 2008; Antinori A et al: Updated research nosology for HIV-associated neurocognitive disorders. Issues in Neurologic Practice 69:1789, 2007; Belle SH et al: Enhancing the quality of life of dementia caregivers from dif­ferent ethnic or racial groups. Annals of Internal Medicine 145:727, 2006; De Jonghe JFM et al: Early symptoms in the prodromal phase of delirium. The American Journal of Geriatric Psychiatry 15:112, 2007; Karuppagounder S et al: Thiamine deficiency in­duces oxidative stress and exacerbates the plaque pathology in Alzheimer's mouse model. Neurobiology of Aging 30:1587, 2008; Lincoln N et al: Driving ability in people with dementia. Alzheimer’s and Dementia 5:P159, 2009; Meuser TM et al: Driving and dementia in older adults: implementation and evaluation of a continuing education project. The Gerontologist 46:680, 2006; Mittel­man MS et al: Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. American Acad­emy of Neurology 67:1592, 2006; Perry JJ et al: Should spectrophotometry be used to identify xanthochromia in the cerebrospinal fluid of alert patients suspected of having subarachnoid hemorrhage? Stroke 37:2467, 2006; Rudolf J et al: Independent vascular and cognitive risk factors for postoperative delirium. The American Journal of Medicine 120:807, 2006; Wimo A et al: An estimate of the total worldwide societal costs of dementia in 2005. Alzheimer’s and Dementia 3:81, 2007.