Dementia & Delirium

Dementia & Delirium Dr Sue Hazel Consultant Geriatrician RBCH Trust

Scope of the Talk • What is dementia? • The different forms of dementia • Symptoms & diagnosis of dementia • Causes of memory problems other than dementia • What is delirium?

Model of the Memory system Seeing Hearing Feeling Short-term memory (working memory) Long-term memory Sensory InputWorking Store Long-term Store Explicit memory Implicit memory Skills Habits Priming Classical conditioning Episodic Memory Events Facts and source Semantic Memory General knowledge

Memory Line DEATH Having to move home MEMORIES Death of spouse Retirement Grandchildren Loss of a parent Having children Getting Married Leaving school Starting work MEMORIES 1st day at school Changing school BIRTH

Dementia • Diagnosis ICD-10 & DSM-IV: Multiple cognitive defects which must include: • Amnesia • Functional impairment • Clear consciousness • Clear change from previous level • Long duration (>6 months)

Who gets Dementia? • There are about 820,000 people in the UK with dementia • Dementia mainly effects people over 65 years of age • There are about 18,500 people in the UK under 65 who have dementia • It effects men & women equally • In a few cases the diseases that cause dementia are inherited

Prevalence of Alzheimer’s Disease Prevalence of Alzheimer’s disease in an aging population. Prevalence increases dramatically with age and approaches 50% of those over 85 years old.(Adapted from Evans et al., 1989.)

Forms of Dementia • Alzheimer’s disease • Vascular Dementia • Dementia in Parkinson’s & Lewy Body Dementia • Frontotemporal Dementia Neurological dementias: Normal Pressure hydrocephalus Cerebral Vasculitis Corticobasal Degeneration Dementia in MS HIV/AIDS Dementia Huntington’s Dementia Prion Diseases - CJD

Prevalence of the forms of dementia

‘Ich habe mich verloren’ Auguste Deter

Alzheimer’s Disease – Diagnosis • Fulfil criteria for dementia syndrome • Insidious onset • Gradual progression • No focal neurological signs • No evidence for a systemic or brain disease sufficient to cause dementia

Alzheimer’s Disease - features Cognitive symptoms: Amnesia – early features are impaired new learning & recall, disorientation in time & place, late features include impaired semantic memory & visuospatial memory Aphasia (dysphasia) – deficits in cortical language function – early features are nominal aphasia, verbal perseveration, late features include mutism & echolalia Apraxia (dyspraxia) – common forms are: ideomotor dyspraxia (cannot carry out motor function to command), dressing dyspraxia, constructional dyspraxia (inability to copy intersecting pentagons or draw a clockface)

Cognitive Features • Agnosiaespecially visual agnosia (inability to recognise objects) & prosopagnosia (inability to recognise faces) • Frontal-executive function – inflexible (concrete thinking). Difficulties with problem solving or planning, difficulty correctly sequencing behaviour. • Dyslexia • Dysgraphia • Acalculia • R/L disorientation

Non-cognitive symptoms • Psychotic: Delusions often paranoid Misidentification Hallucinations commonly visual • Mood: Depression Anxiety Euphoria Behavioural: Apathy Over activity Aggression

Non-cognitive symptoms • Neurovegetative Symptoms: Sleep disturbance, day-night reversal in about 30% patients Eating: poor oral intake or binge eating Sexual disinhibition Personality change • Physical Symptoms: Primitive reflexes (grasp & palmomental reflexes) Incontinence (often a late feature in AD) Weight loss Deterioration in gait Falls

Dementia with Lewy Bodies (DLB) Lewy bodies: neuronal inclusion bodies found in: • The substantia nigra, locus coerulus, amygdala & olfactory bulb in PD & in: • Cortical areas especially the frontal & temporal neocortex in DLB

Dementia with Lewy Bodies (DLB) Evidence of dementia with: • Two of the following core features are essential in order to diagnose possible DLB: Fluctuations: with marked variation in cognition, attention, conscious level, mobility & coherence probably due to cholinergic mechanisms Spontaneous features of parkinsonism: rigidity, bradykinesia & tremor with adverse reactions to dopamine antagonists Visual hallucinations: usually well formed & detailed: people & animals. Vivid dreams which may involve REM sleep behaviour disorder where people enact their dreams.

Dementia with Lewy Bodies (DLB) Other supportive features: • Falls • Syncope • Systematised delusions • Hallucinations in modalities other than vision DLB vs. PD & dementia ‘Rule of thumb’ if the symptoms of dementia precede or present within one year of the diagnosis of PD then the diagnosis is likely to be DLB

Vascular Dementia I. Criteria for the clinical diagnosis of probable vascular dementia: 1. Dementia 2. Cerebrovascular disease: focal signs on neurological examination +/- evidence of cerebrovascular disease on CT or MRI 3. A relationship between the above 2 disorders: (a) Onset of dementia within 3 months of a stroke (b) Abrupt deterioration in cognitive functions or fluctuating stepwise progression of cognitive deficits Other features: Gait disturbance Falls Urinary symptoms

Vascular Dementia Periventricular small vessel disease (Ischaemia)

Frontotemporal dementia - Features • Usual age of onset - < 65 years, often a family history • Behavioural disorder – insidious onset, early loss of insight, early signs of disinhibition & lack of judgement, mental rigidity, stereotypical behaviour, hyperorality • Affective Symptoms – depression, anxiety, apathy, hypochondriasis & somatisation • Speech Disorder– reduction in speech, perseveration, echolalia, mutism • Physical signs – early primitive reflexes, early incontinence, low & labile blood pressure • Investigations – normal EEG, abnormalities of frontal & anterior temporal lobe on imaging

Diagnosing Dementia • Differential diagnosis: • Delirium • Learning disability • Depression – ‘pseudo-dementia’ • Previous brain injury e.g. trauma, stroke • Aging

Memory Complaints in Aging, Depression & Dementia

Diagnosing Dementia –The History • Duration, fluctuation, progression of problems • Forgetfulness / repetitiveness • Misplacing or losing things • Reasoning & judgement e.g. finances / Insight • Safety concerns • Change in personality or behaviour • Night time disturbance • Loss of hygiene • Falls • PMH & medication compliance

Diagnosing dementia – mental state examination • Appearance & behaviour • Speech • Mood • Abnormal beliefs (delusions) • Abnormal perceptions (hallucinations) • Personality – present & previous • Insight • Cognition: MMSE, Frontal Lobe Score, ADAS-Cog, ACE-R

Diagnosing dementia – Physical Examination A full physical examination should be carried out looking for: • Focal neurological weakness • Evidence of parkinsonism • Evidence of dyspraxia • Evidence of anaemia or hypothyroidism • Evidence of intercurrent illness causing a delirium

Diagnosing Dementia- Investigations • Bloods: FBC, U&Es, LFTs, Calcium, Glucose, TFTs, B12, Folate • CT or MRI brain if you suspect: cerebral tumour, normal pressure hydrocephalus, subdural haematoma, & to assess degree of vascular change • DaTSCAN (ioflupane SPECT) if suspect DLB but clinical uncertainty • EEG: generally not helpful but is abnormal in classical sporadic Creutzfeldt-Jacob Disease (triphasic waves)

DaTSCAN in DLB Normal DaTSCAN DaTSCAN in PD & DLB – Decreased dopaminergic neurones in the striatal area

Management of Dementia • Assess for physical illness & depression • Establish functional abilities & any risks • Carer assessment • Education of carers • Planning for future care • Cholinesterase inhibitors • Management of behavioural problems • Terminal care

Anti-dementia drugs • Cholinesterase inhibitors: Donepezil: A reversible inhibitor of acetyl cholinesterase Galantamine: As for Donepezil+ nicotinic receptor agonist Rivastigmine: Non-competitive inhibitor of acetyl cholinesterase, Licensed for dementia in PD • N-methyl-D- aspartate (NMDA) receptor antagonist: Memantine: Some evidence it is effective in more advanced dementia, & beneficial in behaviourally disturbed AD in conjunction with a cholinesterase inhibitor

What do NICE say? (March 2011) • The cholinesterase inhibitors can be prescribed for clinically mild or moderate AD or those with an MMSE 10-24 • Memantine is recommended as an option for managing people with moderate AD who are intolerant / have a contraindication to cholinesterase inhibitors or for severe AD • Only specialists in Old Age Psychiatry or those geriatricians with specific expertise may start therapy • Patients need to be reviewed at 3/12 & then 6/12 intervals to assess response with an MMSE score, a global functional & behavioural assessment & carer views to be considered • If benefit noted they may continue on therapy until the MMSE<10

Environmental Interventions Create a calm environment Turn off TV / radio Take person to a quiet area Remove objects that can be used as weapons Dim lighting if possible Behavioural Interventions Talk slowly & softly Never turn your back on the patient Place yourself between the exit & the patient Innocuous questions e.g. what did you have for lunch can be a distraction Convey concern Allow patient to verbalise feelings Use restraint if necessary Management of Aggression • Medical interventions • Consider a physical cause for agitation e.g. constipation, pain, urinary retention • Consider issues relating to the patient’s mental capacity / DOLS • Review medications as appropriate

Pharmacological interventions Indications for sedation: • In order to carry out essential investigations or treatment • To prevent a patient endangering themselves or others • To relieve distress in a highly agitated or hallucinating patient, after assessing whether there is a physical cause for that distress

Pharmacological intervention Acutely: Haloperidol, Olanzapine and Lorazepam are the drugs of choice Do not use Haloperidol in patients with Parkinson’s disease or Dementia with Lewy Bodies Medium term :Haloperidol or atypical antipsychotics: (up to 6 weeks) Amisulpiride, Quetiapine, Olanzapine, Risperidone (caution in cerebrovascular disease) Longer term: Cholinesterase inhibitors, NMDA Receptor antagonists

Organising your affairs & making your wishes known • Advance Care Planning – how do you wish to be cared for in the future? • Talk to your nearest & dearest about what your wishes are whilst you still can – it will help them & you in the future • The Alzheimer’s Society is an excellent source of information & support Lasting Power of Attorney Finance & Property Health & Welfare

Delirium • Accounts for 30% of all elderly medical in-patients • Can occur in up to 50% of older patients postoperatively • Occurs in about 80% people at the end of life • In studies, patients with delirium have a high mortality rate (22-76%), they have a high rate of discharge to residential care & have longer length of stay than non-delirious patients

Diagnosis of delirium • For a diagnosis a person must show each of the following features: 1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention 2. A change in cognition (memory deficit, disorientation, language disturbance) or the development of perceptual disturbance which was not present with a pre-existing dementia 3. The disturbance occurs over a short time (usually hours or days) & fluctuates during the day 4. There is evidence that it has been caused by general medical condition, substance intoxication or withdrawal

Psychomotor Forms of Delirium • Hyperactive: Marked by increased motor activity, agitation, hallucinations, inappropriate behaviour & vigilance • Hypoactive: Marked by lethargy with a decrease in motor activity, has a poorer prognosis. It is often missed (up to 2/3rds cases) • Mixed

Pathogenesis • EEG can show diffuse slowing of cortical background activity • Neuropsychological & neuro-imaging studies show generalised disruption in higher cortical function • Cholinergic deficiency – anti- cholinergic drugs can precipitate delirium & physostigmine & cholinesterase inhibitors can reverse delirium • Dopaminergic excess – levodopa can precipitate delirium & dopamine antagonists can reverse it • Evidence also exists for the role of other neurotransmitters but less strong

Risk factors for delirium developing as an inpatient • Old age • Severe illness • Pre-existing dementia, depression or previous delirium • Physical frailty – functional dependence, falls • Infection • Dehydration or malnutrition • Sensory impairment • Polypharmacy especially with psychoactive drugs • Surgery especially #NOF • Previous alcohol excess • Renal or hepatic impairment • Metabolic derangement e.g. hyponatraemia • Terminal illness

Precipitating factors for delirium as an inpatient • Immobility • Use of physical restraint • Urinary catheter • Malnutrition • Dehydration • Intercurrent illness • Psychoactive medications • Inadvertent withdrawal of psychoactive medications e.g. benzodiazepines • Iatrogenic events

Common intercurrent illnesses in delirium • Infection • Cardiac – MI, heart failure • Respiratory – PE, hypoxia • Electrolyte imbalance – dehydration, renal failure, hyponatraemia, hypercalcaemia • Endocrine & metabolic – cachexia, thiamine deficiency, thyroid dysfunction • Drugs especially those with anti-cholinergic side effect • Urinary retention • Faecal impaction • Neurological – stroke, SDH, epilepsy, encephalitis

Differential Diagnosis of delirium • Dementia • Depression • Hysteria • Mania • Schizophrenia • Dysphasia • Non convulsive epilepsy / temporal lobe epilepsy

Assessment of delirium • Confusion Assessment Method (CAM) To have a positive CAM the patient must have: • Presence of an acute confusion, a fluctuating course AND • Inattention (e.g. impaired 20-1 counting on AMTS or the inability to spell WORLD backwards on MMSE) AND EITHER • Disorientated thinking (disorganised or incoherent speech) OR • Altered level of consciousness ( usually lethargic or stuporose)

Assessment of delirium • Collateral history from a carer or the NOK is essential to establish the onset & course of confusion to distinguish between dementia & delirium • Assess for cause of delirium • Assess cognitive function if possible on admission (AMTS or MMSE) & subsequent serial measurements can track patients’ progress

Assessment in delirium – the history • Previous intellectual function & functional status • Full drug history including recent cessations • History of fluid & food intake, alcohol history • History of bladder & bowel voiding • Sensory deficits & aids used • Previous episodes of acute or chronic confusion • Co morbidities • Symptoms suggestive of underlying cause • Pre-admission social circumstances & care package

Investigations in delirium • Routine bloods, ECG, CXR, urinalysis, pulse oximetry, blood cultures, TFTs, B12 , Folate • CT head if: Focal neurological signs Confusion after fall or head injury • EEG if : Suspect non-convulsive status or temporal lobe epilepsy • LP if: Meningism, headache & fever

Management of Delirium -Treatment of Underlying Cause • Incriminating drugs should be withdrawn where possible • Biochemical derangements corrected • Treatment of infection • Parenteral thiamine should be administered if malnutrition or alcohol excess is suspected

Management of Confusion - Environment • Lighting levels appropriate for the time of day • Regular (at least 3xday) cues to orientate • Use of clocks & calendars • Hearing aids & glasses available & functioning • Continuity of care from nursing staff • Encouragement of mobility & engagement in activities • Approach & handle gently, explain who you are, what you are going to do & why

Environment Contd. • Elimination of unexpected & irritating noise • Good pain control- use of Abbey Pain Scale • Encourage visits from family & friends especially at meal times • Explain to family what delirium is & how they can help • Ensure adequate fluid & dietary intake • Adequate CNS oxygen delivery • Monitor bowels – avoid constipation • Encourage a good sleep pattern • Avoid inter & intra ward transfers • Avoid catheters where possible

Dementia & Delirium