Dementia and Delirium - Johns Hopkins Medicine

Dementia and Delirium · Acute onset (hours/days) and a fluctuating course · Inattention or distraction · Disorganized thinking or a altered level of consciousness. SkipNavigation ImportantUpdates:COVID-19vaccinations|RecallonPhilipsRespironicsmedicaldevices COVID-19:Wearevaccinatingpatientsages12+.Learnmore: Vaccines,Boosters&AdditionalDoses|Testing|PatientCare|VisitorGuidelines|Coronavirus|Self-Checker|EmailAlerts   PhilipsRespironicsissuedarecallforsomeCPAPandBiLevelPAPdevicesandmechanicalventilators.Learnmore. FindaDoctorAppointmentsLogintoMyChart Search Search About AboutJohnsHopkinsMedicine Centers&Departments PatientSafety&Quality Maps&Directions News&Publications CommitmenttoCommunity FortheMedia Careers ContactUs MakeaGift HopkinsMedicineHome IWantTo... FindaDoctor RequestanAppointment ReferaPatient ApplyforaJob MakeaGift PayMyBill Health HealthHome ConditionsandDiseases Treatments,TestsandTherapies WellnessandPrevention Caregiving IWantto... 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InThisSection      Home > GeriatricWorkforceEnhancementProgram > LectureSeries DementiaandDeliriumbyJohnBurton,M.D.IntroductionCausesandRiskFactorsDiagnosisAssessmentTreatmentDementiaVs.DeliriumReferencesIntroductionDementiaisaprogressivedeclineinmemoryandatleastoneothercognitiveareainanalertperson. Thesecognitiveareasincludeattention,orientation,judgment,abstractthinkingandpersonality. Dementiaisrareinunder50yearsofageandtheincidenceincreaseswithage;8%in>65and30%in>85yearsofage.(topofpage)CausesandRiskFactorsThereareseveralriskfactorsfordementia:AgeDown’sSyndromeHeadinjuryFeweryearsofeducationFemaleGenetics* Earlyonsetofmutationsinchromosome1,14,and21* Lateonsetofmutationsinchromosome19    -apolipoproteinEgen(APOE2,3,and4)    4/4greatestrisk(3%ofpopulation)     3/4nextrisk(20%ofpopulation)    2maybeprotective APOE4neithernecessarynorsufficienttocausedementia* GeneticscreeningisnotrecommendedDementiaresultsfrombraindamage. Thecausesincludethefollowing;Alzheimer’sDisease,Stroke,Pick’sdisease,Huntington’s,DownsSyndrome,Creutzfeldt-Jacob,AIDS,alcoholism,Parkinson’sdiseaseandotherneurodegenerations.(topofpage)DiagnosisTherearethreepurposeswhydiagnosingdementiaisessential. Bydeterminingtheprobablecause,treatabledisorderscanbeidentified,suchasmedicationtoxicity(benzos,H2blockersandanticholinergics),andthyroiddisease.Therearesymptomsandcomorbiditiesthataretreatable,suchasdepression,delirium(seebelow),delusions,hallucinations,andagitation.Caregiversmustbeidentifiedandenvironmentalissuestakenintoconsideration.Adiagnosisofdementiaisbasedon:memoryloss-bothinshortandlong-term,plusoneormoreofthefollowing:aphasia–languageproblemsapraxia–organizationalproblemsagnosia–unabletorecognizeobjectsortelltheirpurposedisturbedexecutivefunction–personalityandinhibition(topofpage)AssessmentAnassessmentfordementiamayincludethefollowing:History,bothfromthepatientandcloseobserversFocusedphysicalMiniMentalStateExamLabworkincludingCBC,basicmetabolicprofile,TSH,VitaminB12,STSIfbraininjuryorspaceoccupyinglesionsuchasatumorisinquestion,CT,or MRI.PETscansareoccasionallyrecommendedintheearlydiagnosisofdementiaalthoughthereremainssomecontroversyastopreciselytheirindicationandvalueAdditionally,depression,delirium(discussedbelow),agitation,hallucinations,anddelusionsareimportantcomorbiditiesthatmustbetakenintoconsideration. Behavioralissuesmayrequireareferraltoaspecialist.(topofpage)TreatmentTherearebothpharmacologicandnon-pharmacologicinterventionsthatmaybebeneficialforpatientswithdementia.Non-pharmacologicInterventions SocialactivitiesAdequatesleepAdherencetoastrictscheduleMaintenanceofaproperstimulationlevelAdequatehydrationReformattingtask(occupationtherapy)SupportcaregiversPharmacologicInterventions(courseistypically10years,but2-20possible)Prevention      *VitaminE,andcognitivestimulationsuchaseducationMemory/attentionAcetylcholinesteraseInhibitors      * Tacrine      * Donepezilhydrochloride      * Rivastigminetartrate      * GalantaminehydrochlorideNMDAantagonists     * Memantine     * Others(Ginkgobiloba,caffeine,nicotine,methylphenidate,NSAIDs)Behavioral      * Antipsychotics     * Antidepressants     * Moodstabililizers(topofpage)DementiavsDeliriumInordertomakeadiagnosisofdementia,deliriummustberuledout. However,patientswithdementiaareatincreasedriskofdeliriumandmayhaveboth. Deliriumisanacutedisorderofattentionandglobalcognition(memoryandperception)andistreatable. Thediagnosisismissedinmorethan50%ofcases. Theriskfactorsfordeliriumincludeage,pre-existingbraindisease,andmedications. Therearemanycauses,themostcommonare:  D  Dementia  E  Electrolytedisorders  L  Lung,liver,heart,kidney,brain  I   Infection  R  RxDrugs  I   Injury,Pain,Stress  U  Unfamiliarenvironment  M  MetobolicPreventionofdeliriumincludestheavoidanceofpsychoactivedrugs,quietenvironment,daytimeactivity,darkandquietatnight,visualandhearingassistivedevices,orientationdevices,andavoidanceofrestraints.Diagnosisofdeliriumisbasedonclinicalobservation;nodiagnostictestsareavailable. Theessestialfeaturesofdeliriuminclude:Acuteonset(hours/days)andafluctuatingcourseInattentionordistractionDisorganizedthinkingoraalteredlevelofconsciousnessTreatmentofdelirium,likedementia,ismanagedbothpharmacologicallyandnon-pharmacologically.Non-pharmacologicmanagementOptimizeenvironmentPersonalbelonging–photographsQuietSitter PharmacologicmanagementNeurolepticsmaybeneededifthepatientishavingdistressinghallucinations/delusionsor   thepatientisveryagitatedHighpotencywithlowanticholinergicactivityLowdoseHaloperidolorrisperdoneBenzodiazepineifdeliriumissecondarytobenzooralcoholwithdrawal(topofpage)ReferencesClinGeriatrMed20(2004)MarchAnnInternMed2004:140;501.VisittheMentalHealthAssociationofMarylandforadditionalinformationandassistance.(topofpage) RequestanAppointmentPatientCare410-550-0925AlreadyaPatient?RequestyournextappointmentthroughMyChart! TravelingforCare?Whetheryou'recrossingthecountryortheglobe,wemakeiteasytoaccessworld-classcareatJohnsHopkins.OutsideofMaryland(tollfree)410-464-6713RequestanA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