Confusion in the Elderly

1. Confusion in the Elderly M Ward Horton January 2011

2. Outline • Personal Case Histories • Group Case Histories • Review of Delirium & Dementia • Literature review

3. Case A • Mrs FG • 92 yr old retired school cook widow • Living alone, malnourished • Tripped over her enormous dog - # NOF • Admitted for DHS • 6 hours post op - agitated, confused • Bloods normal • CT Brain normal

4. Case A • Altered level of consciousness • No focal or lateralizing signs • MRI Brain - DWI - acute infarct right & left parietal lobes • Started aspirin 300mg • 48 hrs later - complete resolution of confusional state - Good recovery

5. Case B • Mr JH • 74 yr old male retired Professor of Hebrew studies • Increasingly vague and distant for 3 months • Increased apathy • Withdrawn • Stopped initiating activities - Passive

6. Case B • Previously fit & well • Prior to the change in character had visited Avignon with wife - caught a nasty viral infection and had been unwell - sore throat,runny nose, myalgia, lethargy for 2-3 weeks • Since then - never returned to previous level of function

7. Case B • Referred by GP - ?memory loss, personality change • Wife very concerned ….. • Clinic - Very mild asymmetric cogwheel rigidity left arm, possible loss of facial expression , normal eye movements • MMSE 30/30 BP 130/70 No drop

8. Case B • CT Brain • CXR • Bloods • 1 monthly review • Trial of Sinemet • Gastritis - referred for OGD • ∆ Gastritis - started on PPI

10. Case B • Small vessel disease

11. Case B • Further review - no significant benefit from sinemet • Current working ∆ Possible vascular parkinsonism • Prior to next monthly review --admitted to HGH with increased tiredness • GP had checked bloods - creat 590 • Renal biopsy - Tubulointerstitial nephritis 2° to PPI

12. Case B • Steroids started - good renal recovery and mentally started to recover • Asymmetric cogwheel rigidity had disappeared • Sinemet withdrawn - no deterioration • Conclusion: Significant Delirium illness

13. Case C • Mrs BT • 86 yr old former ballerina • 6 month history of increasingly mild forgetfulness , decreased mobility, ?incontinence • Lives alone with informal support network • Admitted at the weekend after calling Police 5 times and next of kin

14. Case C • Agitated and confused • Rambling conversation • No focal neurological deficit • No neck stiffness • Bloods normal, urine dip -ve • CT Brain

16. Case C • ∆ Normal Pressure Hydrocephalus • LP - 40 mls withdrawn • CSF normal • No symptomatic improvement • Good nursing care • Less agitated - MMSE 17/30 • ∆

17. Case D • Mrs EB found wandering by husband • Acutely confused • Brought to ED • 2 seizures in ED • CT Brain - Small vessel disease, old lacunar infarct • Bloods -

18. Case D • Confusion persisted for 24 hrs • Then resolved • TROP 3.4

19. Acute Confusional State • This state is at one end of the spectrum of disordered levels of consciousness • The other end - coma • Disordered LOC reflects either a bilateral cortical insult or focal brainstem insult

20. Plum & Posner (1980) • Assessment of patient with stupor or coma: • Stupor/coma with focal/lateralizing signs above or below tentorium • Stupor/coma with signs of meningeal irritation • Stupor/coma related to toxic/metabolic insults

21. P & P • Allows rapid determination of which path to follow in the acute presentation of illness • Toxic/metabolic causes most common • Followed by focal/lateralizing signs

22. Stupor/Coma • This approach helps you to rule out catastrophic, potentially treatable illness • Helps you determine whether patient needs urgent neuroimaging and LP

23. Delirium • Can occur in the setting of a specific neurological insult - stroke, psychotropic medication, SAH, encephalitis • Can occur in anyone ill enough • Historically, delirium noted to be a non-specfic marker of illness - a geriatric giant • Theoretically any illness could give rise to delirium • Hence books contain long lists of causes of delirium

24. Delirium • Reality - common illnesses make up the vast majority of cause of delirium • Previously delirium was felt to be short lived - however, the current literature suggests some patients experience persistence of problems for some time

25. Delirium DSM-IV • Disturbance of consciousness ie reduced clarity of awareness of the environment , with reduced ability to focus,sustain or shift attention • A change in cognition ie memory deficit, disorientation, language disturbance • Disturbance tends to develop over short period of time and tends to fluctuate during the day • Medical examination, lab findings linked to direct physiological consequence of a gen med condition

26. Pathophysiology • Delirium essentially a disorder of arousal and attention - involving RAS and nucleus basalis of Meynert • Cholinergic deficiency demonstrated • CRP link

27. Delirium • Prevalence - gen int med 15-25% • Amongst older pts in surgery - ≥66% • Highest rates are those who are frail and those with dementia

28. Predisposing Advanced age Frailty Dementia Psychiatric illness Malnutrition Chronic anticholinergic drug use Precipitating Any acute illness Any medication Withdrawal of meds Any trauma Any anaesthetic Environmental change Delirium

29. Management • Identify & treat underlying cause • No RCTs for pharm Mx of delirium • Supportive care - skilled calm care appreciated by delirious patients

30. Prognosis • Difficult to give accurate figures due to wide variety of methods that delirium has been diagnosed the literature- hence some patients with delirium have dementia • However, patients tend to be frail, have underlying cognitive impairment • Studies suggest increased LOS • Increased rate of discharge to NH • Increased mortality

31. Dementia • Acquired impairment of intellectual and memory function caused by disease of the brain • Not associated with disordered LOC

32. New Imaging Techniques and the Diagnosis of Dementia Case

33. Case HistoryJuly 2008 63, vehicle welder, lives Swindon Referred to OXMAC Jul 2008 5 year history memory problems Simple memory lapses Conversations Appointments Daily Continuous

34. Case History Had been seen in another memory clinic over period of few years Diagnosis = mild cognitive impairment GP wished second opinion ‘Long term implications of this diagnosis, could any improvement be foreseen’

35. Case History Working as welder, no problems with work Driving, often on own, probably ok Anxiety, shaking and hyperventilation episodes Low mood Worse mornings, improves thro’ day Abnormal sleep Treatment Fluoxetine

36. Examination Mild evidence of parkinsonism Immobile face, difficulty turning, reduced arm swing particularly on left MMSE 26/30 Hopkins Verbal Learning Test 26/36 Clox 11 and 14/15

37. Case History Seemed depressed Increase Fluoxetine Parkinsonism mild, but may be relevant

38. Case HistoryOctober 2008 Reviewed clinic Oct 08 More marked parkinsonism Cog-wheeling right arm Driving worse according to wife (roundabouts / too slow) Probably worsening cognition despite increased Fluoxetine Still working

39. Case History MMSE 25/30 No clear fluctuation No clear history hallucinations Considering diagnosis early dementia DaT scan

40. Case HistoryJanuary 2009 Seen clinic Jan 09 Worsening Parkinsonism Balance and gait deteriorating and affecting work Prominent dreams, no hallucinations MMSE 22/30 CLOX 8+14 HVLT 25/36

41. Case History Diagnosis likely Dementia with Lewy Bodies

42. Case HistoryApril 2009 Seen in PD clinic April 09 Started L-Dopa

43. 62M ‘Unresponsive PD’

44. Case 64M