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DELIRIUM

AND

DEMENTIA

DANA BARTLETT, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16

years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material and

textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of

toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring

nurses, emergency medical residents and pharmacy students.

ABSTRACT

There are many possible causes of dementia and delirium. The more

common causes are complex, such as dementia of the Alzheimer’s

type or delirium due to drug withdrawal. Other relevant neurological

problems include mild cognitive impairment and pseudo-dementia.

While detailed and extensive information about the specific causes of

these diseases is outside the scope of this study, general information

on dementia and delirium, including risk factors, treatments, and

nursing considerations are discussed.


Accreditation Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses.

Credit Designation

This educational activity is credited for 4.5 hours. Nurses may only

claim credit commensurate with the credit awarded for completion of

this course activity.

Pharmacology content is 0.5 hours (30 minutes).

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity,

transparency, and best practice in clinical education for all continuing

nursing education (CNE) activities. All authors and course planners

participating in the planning or implementation of a CNE activity are

expected to disclose to course participants any relevant conflict of

interest that may arise.

Statement of Learning Need

Nurses in all practice settings that care for individuals with dementia

and delirium need to understand what defines each disorder, and

diagnostic criteria related to etiology, clinical assessment and signs

and symptoms.


Course Purpose

To provide professional nurses with the information they need to

assess and care for patients who have dementia or delirium.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author & Director Disclosures

Dana Bartlett, RN, BSN, MA, MSN, CSPI, William S. Cook, PhD,

Douglas Lawrence, MS, Susan DePasquale, MSN, FPMHNP-BC - all

have no disclosures.

Acknowledgement of Commercial Support

There is none.

Please take time to complete a self-assessment of knowledge,

on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge

learned will be provided at the end of the course.


1. One of the defining characteristics of dementia is

a. inability to perform activities of daily living.

b. severe agitation. c. reversible cognitive impairment.

d. occurrence before age 50.

2. Most cases of dementia are caused by

a. trauma and heavy metal poisoning. b. infections and hemorrhage.

c. Alzheimer’s disease and vascular pathologies. d. hypoxia and Parkinson’s disease.

3. Defining characteristics of delirium include

a. movement disorders and a progressive cognitive decline. b. attention deficits and confusion.

c. expressive aphasia and hypotension. d. hyperthermia and depression.

4. The onset of delirium is

a. acute.

b. slow. c. chronic.

d. fluctuating.

5. Common causes of delirium include

a. Parkinson’s disease and advanced age.

b. drug withdrawal and Lewy body dementia. c. acute blood loss and frontotemporal dementia.

d. drugs and dementia.


Introduction

Dementia and delirium are the major causes of cognitive impairment

in the elderly, and they are syndromes caused by a wide range of

medical, neurological and psychiatric pathologies.1 As clinical

diagnoses, dementia and delirium can be confirmed through

investigation into etiology, laboratory testing, specific physical

findings, or imaging. In addition, the relationship between the two

diseases is complex. There are similarities in their presentation;

dementia is a major risk factor for delirium, and delirium occurs in

many patients who have dementia. Dementia and delirium can be

acute or subacute, and they can be transient and reversible or they

can cause permanent impairment. Both dementia and delirium are

associated with increased morbidity and mortality, and their risk

increases with advancing age. As the population in the U.S. becomes

older the incidence of these pathologies of aging will certainly increase.

Overview Of Delirium And Dementia

Slowing of cognitive function can occur with aging and it is not

uncommon for older people to have mild memory deficits or a

decreased speed with which information is processed. Old age is a

major risk factor for dementia, but advanced age itself does not cause

a decrease in cognitive and intellectual ability that interferes with daily

functioning. In brief, dementia is not an inevitable consequence of

getting old.


Statistics

Dementia and delirium are very common. The incidence and

prevalence rates of dementia and delirium are reflected in the

following prevalence rates.1-5

Delirium is noted in 14%-56% of elderly patients who are

hospitalized and in 40% of patients admitted to intensive care.

Postoperative delirium is seen is approximately 5%-10% of

general surgery patients.

Community-based studies have found a prevalence of dementia

as high as 47% in those 85 years of age and older.

Alzheimer’s disease is the most common cause of dementia and

in 2013 there were approximately 5 million Americans who

suffered from Alzheimer’s disease.

There are many causes of dementia but Alzheimer’s disease

accounts for approximately 60%-80% of all cases.

Delirium occurs in approximately 50% of older hospitalized

patients and 70% of older long-term care patients.

Dementia: Definition, Diagnostic Criteria And Etiology

Dementia can be defined in several ways. Kane, et al. (2013) defines

dementia as “... a clinical syndrome involving a sustained loss of

intellectual functions and memory of sufficient severity to cause

dysfunction in daily living.”1 This definition emphasizes key points

about dementia that are important to remember.

First, the distinguishing aspect of dementia is an inability to

successfully perform the activities of daily living, caused by impaired

cognitive and intellectual capacity. Second, dementia is a syndrome. A

syndrome is a set of signs and symptoms that can have many different


causes, and that is especially true with dementia. There is a multitude

of etiologies of dementia. And finally, because dementia has no single

cause or type of cause the clinical picture of dementia can be variable.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition,

(DSM-5) has replaced the term dementia with the terms major

cognitive disorder and mild cognitive disorder.6

Major Neurocognitive Disorder: DSM-5 Diagnostic Criteria

1. Evidence of significant cognitive decline from a previous level of

performance in one or more cognitive domains (complex

attention, executive function, learning and memory, language,

perceptual-motor, or social cognition) based on: a) concern of

the individual, b) a knowledgeable informant or the clinician

finds there has been a significant decline in cognitive function;

and, c) a substantial impairment in cognitive performance,

preferably documented by standardized neuropsychological

testing or, in its absence, another quantified clinical assessment.

The cognitive deficits interfere with independence in everyday

activities (i.e., at a minimum, requiring assistance with complex

instrumental activities of daily living such as paying bills or

managing medications).

2. The cognitive deficits do not occur exclusively in the context of a

delirium.


3. The cognitive deficits are not better explained by another mental

disorder (i.e., major depressive disorder, schizophrenia).

Minor Neurocognitive Disorder: DSM-5 Diagnostic Criteria

1. Evidence of modest cognitive decline from a previous level of

performance in one or more cognitive domains (complex

attention, executive function, learning and memory, language,

perceptual-motor, or social cognition) are based on a) concern of

the individual, b) a knowledgeable informant, c) the clinician’s

assessment of a mild decline in cognitive function, and d) a

modest impairment in cognitive performance, preferably

documented by standardized neuropsychological testing or, in its

absence, another quantified clinical assessment.

2. The cognitive deficits do not interfere with capacity for

independence in everyday activities (i.e., complex instrumental

activities of daily living such as paying bills or managing

medications are preserved, but greater effort, compensatory

strategies, or accommodation may be required).

3. The cognitive deficits do not occur exclusively in the context of a

delirium.

4. The cognitive deficits are not better explained by another mental

disorder (i.e., major depressive disorder, schizophrenia).

When making the diagnosis of major or minor neurocognitive disorder

it must be specified if the disorder is due to one of the following:


Alzheimer’s disease

Frontotemporal lobar degeneration

Lewy body disease

Vascular disease

Traumatic brain injury

Substance/medication use

HIV infection

Prion disease

Parkinson’s disease

Huntington’s disease

Another medical condition

Multiple etiologies

Unspecified

Dementia can be usefully divided

into two categories: reversible and

irreversible. Most cases of

dementia are irreversible. These

dementias slowly progress and the

patient’s condition worsens over

time.

Degenerative diseases of the

nervous system, infections,

trauma, and vascular disorders

cause irreversible dementias. The

most common irreversible dementias are dementia of Alzheimer’s

disease, frontotemporal dementia, Lewy body dementia, Parkinson’s


disease, and vascular dementia. Many patients who have dementia

have a neurodegenerative and a vascular pathology.7

Table 1: Irreversible Causes of Dementia1

Acquired immunodeficiency syndrome

Alzheimer disease

Anoxia secondary to cardiac arrest

Arteritis

Binswanger disease

Carbon monoxide poisoning

Cerebrovascular disease, i.e., multi-infarct dementia

Craniocerebral injury, including dementia pugilistica

Creutzfeldt-Jakob disease

Huntington’s disease

Dementia associated with Lewy bodies

Frontotemporal dementia

Infections


Pick disease

Postencephalitic dementia

Progressive multifocal leukoencephalopathy

Progressive supranuclear palsy

Trauma

Vascular dementias

The reversible dementias are much less common than the irreversible

dementias. Irreversible dementias can be successfully treated but

finding and treating the cause does not guarantee a cure.


Table 2: Reversible/Partially Reversible Causes of Dementia1

Alcoholism

Anoxic brain injury

Autoimmune disorders

Central nervous system vasculitis

Disseminated lupus erythematous

Depression

Drugs

Heavy metal poisoning, i.e., lead, mercury

Infections

Metabolic disorders

Multiple sclerosis

Neoplasms

Normal pressure hydrocephalus

Nutritional disorders, i.e., B6, B12 deficiency

Organic poisons, i.e., pesticides, solvents

Psychiatric disorders

Trauma

Viral infections, i.e., HIV

Medications, prescription or illicit, can also cause dementia. In most

cases the dementia caused by a drug is reversible, but not always. The

following Table 3 lists the drugs that can cause dementia and delirium.


Table 3: Drugs That Can Cause Dementia and Delirium1

Alcohol

Analgesics

Anti-arrhythmics

Anticholinergic agents

Anti-convulsants

Antidepressants

Antihypertensives

Anti-psychotics

Anxiolytics

Digoxin

H2 receptor antagonists

Non-steroidal anti-inflammatories

Sedative-hypnotics

Skeletal muscle relaxers

Steroids

There is a wide range of causes of dementia, but there are similarities

in their clinical presentation.

Irreversible dementia is typically progressive, the signs and

symptoms worsening over a course of months and years. The

course is individualized with no predictability as to its pattern.

There is typically no disturbance of consciousness: the patient is

awake, alert, and responsive.

Memory loss is the most prominent cognitive disability of

dementia.

Impairment of language, visuospatial ability, calculation,

judgment, and problem solving - what are called the executive


brain functions - are also common in patients who have

dementia.

Patients who have dementia often suffer from neuropsychiatric

problems including, but not limited to, agitation, apathy,

delusions, depression, disinhibition, hallucinations, insomnia, and

wandering.

As mentioned previously, the most common causes of irreversible

dementia are Alzheimer’s disease, frontotemporal dementia, Lewy body

dementia, Parkinson’s disease, and vascular dementia. Some of these

may not be familiar to many nurses and a brief description of each one

is provided below.

Alzheimer’s Disease

Alzheimer’s disease is a chronic, progressive neurological disorder that

causes severe behavioral and cognitive deterioration, especially in

memory. The cause, or causes, of Alzheimer’s disease are not

completely understood. Alzheimer’s disease is probably the result of a

convergence of genetic risk factors and environmental stimuli that

produce characteristic lesions in the parietal and temporal lobes,

specifically amyloid plaques and neurofibrillary tangles. These lesions

interrupt the normal metabolism and self-repair of neurons and disrupt

communication between different areas of the brain.

The time from diagnosis to death can be as little as three years. The

signs and symptoms of Alzheimer’s disease are difficult to treat and

there is no cure.


Frontotemporal Lobe Dementia

Frontotemporal lobe dementia is a neurodegenerative disease caused

by atrophy of the frontal and temporal lobe. It is a disease that is

considered clinically and genetically diverse. The hallmark signs of

frontotemporal dementia are behavioral and speech defects, such as

expressive and fluent aphasia and abnormal personal and social

behavior. In most cases the cause is unknown, however, a family

history of the disease is a strong risk factor. Frontotemporal dementia

is chronic, progressive, and there is no cure.

Lewy Body Dementia

Lewy body dementia is a chronic, progressive neurodegenerative

disease that is characterized by the presence of Lewy bodies,

abnormal deposits of protein that accumulate in neurons in specific

areas of the brain. The cause of Lewy body dementia is not known. It

is distinguished from other types of dementia by the Lewy bodies and

by these aspects of the clinical presentation:

Varying levels of alertness and attention, especially reduced

responsiveness

Visual hallucinations

Parkinsonian motor signs

There appears to be some overlap of Lewy body dementia with

Alzheimer’s disease and Parkinson’s disease with dementia. Lewy

bodies are noted in some patients with Alzheimer’s disease (Lewy body

variant of Alzheimer’s disease) and in some patients with Parkinson’s

disease. Additionally, some of the signs of Parkinson’s disease with


dementia and Lewy body dementia are similar. There is no cure for

Lewy body dementia.

Parkinson’s Disease

Parkinson’s disease is caused by chronic and progressive destruction of

dopamine-producing cells in the substania nigra area of the brain.

Parkinson’s disease often causes dementia, but it is distinguished by

characteristic motor symptoms such as bradykinesia (slowness of

movements), gait disturbances, rigidity, and tremor.

Approximately 10% of all cases of Parkinson’s can be clearly identified

as having a genetic cause, but most cases are considered to be caused

by a convergence of genetic risk factors and environmental stimuli.

There is no cure for Parkinson’s disease but there is effective

symptomatic treatment and the progression of the disease can be

delayed.

Vascular Dementia

Vascular dementia is the second most common cause of dementia and

it often coexists with Alzheimer’s disease. Vascular dementia is not a

single disease; it is a group of syndromes that are caused by vascular

pathologies, such as:

Cerebral infarct

Cerebral hemorrhage

Embolic and/or thrombotic obstructions (i.e., stroke)

Various types of lesions like lacunar lesions


There are many causes of vascular dementia, and athersclerosis,

diabetes, hypercholesterolemia, hypertension, and smoking are

significant risk factors for the development of this pathology.

Delirium: Definition, Diagnostic Criteria And Etiology

Delirium is an acute change in mental status characterized by

confusion and disturbances in cognition.9 Delirium is a sudden change

in cognition. It develops over a short period, it fluctuates in severity,

and the most prominent features of delirium are the abnormal changes

that occur in attention and awareness. As with dementia, delirium is a

syndrome, there are a multitude of causes, and the clinical

presentation can vary. Delirium is usually transient and reversible, but

delirium can persist for hours or days (acute) or weeks or months

(persistent), and it is associated with high rates of morbidity and

mortality. The DSM-5 criteria for delirium are:9

Delirium: DSM-5 Diagnostic Criteria

1. A disturbance in attention (i.e., reduced ability to direct, focus,

sustain, and shift attention) and awareness (reduced orientation

to the environment).

2. The disturbance develops over a short period of time (usually

hours to a few days), represents a change from baseline

attention and awareness, and tends to fluctuate in severity

during the course of a day.

3. An additional disturbance in cognition (i.e., memory deficit,

disorientation, language, visuospatial ability, or perception).


4. The disturbances in Criteria A and C are not better explained by

another preexisting, established, or evolving neurocognitive

disorder and do not occur in the context of a severely reduced

level of arousal, such as coma.

5. There is evidence from the history, physical examination, or

laboratory findings that the disturbance is a direct

physiological consequence of another medical condition,

substance intoxication or withdrawal (i.e., due to a drug of abuse

or to a medication), or exposure to a toxin, or is due to multiple

etiologies.

When making the diagnosis of delirium it must be specified if the

delirium is hyperactive, hypoactive, or involves a mixed level of

activity, and associated with the following symptoms.

Hyperactive:

The individual has a hyperactive level of psychomotor activity

that may be accompanied by mood lability, agitation, and/or

refusal to cooperate with medical care.

Hypoactive:

The individual has a hypoactive level of psychomotor activity

that may be accompanied by sluggishness and lethargy that

approaches stupor.


Mixed level of activity:

The individual has a normal level of psychomotor activity even

though attention and awareness are disturbed. Also includes

individuals whose activity level rapidly fluctuates.

A hyperactive level of psychomotor activity characterizes hyperactive

delirium, and is it seen in patients who are intoxicated or in withdrawal

from drugs such as amphetamine or phencyclidine. A decreased level

of psychomotor activity characterizes hypoactive delirium, and the

patient is lethargic and sluggish. Mixed state delirium is characterized

by alternating periods of agitation and sedation.

As with dementia, there are many causes of delirium. Drugs and

medications are an important and common cause of delirium.

Dementia is also a very common cause of delirium. Delirium can

happen to any patient, but it is more prevalent in the elderly.

It is not clear if advanced age itself is a risk factor for delirium.

However, the elderly patient population often has greater exposure to

identified risk factors for delirium; bladder catheterization, decreased

ability to metabolize and eliminate medications, dementia, fracture,

hearing impairment, immobility, inadequate or excessive use of

analgesics or sedatives, malnutrition, multiple medications, pre-

existing dementia, sensory deprivation, status-post anesthesia and

surgery, underlying medical or neurologic illnesses, use of physical

restraints, and visual impairment.1,5,9 Common causes of delirium are

listed in Table 4 below.


Table 4: Common Causes of Delirium1,8

Acute blood loss

Acute myocardial infarction

Acute psychoses

Azotemia

Congestive heart failure

Decreased cardiac output

Decreased sensory input

Dehydration

Dementia

Drugs

Drug overdose

Drug withdrawal

Dehydration

Fecal impaction

Fracture

Intoxication

Hypercarbia

Hypo- or hyperglycemia

Hyponatremia

Hypo- or hyperthermia

Hypoxia

Immobility

Infections

Malnutrition

Metabolic disorders

Post-Operative State


Stroke (small cortical)

Urinary retention

Visual impairment


Delirium is often misdiagnosed and it may be mistaken for dementia,

depression, another psychiatric disorder, or attributed to old age.9 This

underrecognition can delay treatment, and it can also prolong the

duration of delirium and expose the patient to permanent neurological

damage.5

Mild Cognitive Impairment And Pseudo-dementia

Mild cognitive impairment (MCI) and pseudo-dementia should also be

mentioned when discussing dementia. Individuals who have MCI or

pseudo-dementia can often develop dementia. MCI is often

overlooked, and pseudo-dementia is often misdiagnosed as dementia.

Mild cognitive impairment is a term used to describe cognitive deficits

that are not considered to be a normal part of aging but do not fit the

diagnostic criteria for dementia.10,11 There are differences in the

diagnostic criteria for MCI and these criteria are not precise, but MCI is

generally considered to be an intermediate state between normal

cognitive functioning and dementia. In their 2014 review, Langa, et

al., used these criteria for the diagnosis of MCI.10

Concern regarding a change in cognition from the patient,

knowledgeable informant, or from a skilled clinician

observing the patient.

Objective evidence of impairment (from cognitive testing)

in 1 or more cognitive domains including memory,

executive function, attention, language, or visuospatial

skills.

Preservation of independence in functional abilities

(although individuals may be less efficient and make more


errors at performing activities of daily living and

instrumental activities of daily living than in the past).

No evidence of a significant impairment in social or

occupational functioning (i.e., not demented).

Patients who have MCI have memory deficits and occasionally they

have subtle defects in other cognitive abilities, but they have normal

executive functioning and they do not have difficulties performing

activities of daily living.10,11 The patient who has MCI is aware of the

change in his/her memory, unlike the person who has dementia. Mild

cognitive impairment may be temporary and a reversion to normal

mental status is possible12 but approximately 5%-20% of people who

have MCI will develop dementia.10

Pseudo-dementia is a descriptive term for a clinical presentation that

closely mimics dementia, but is usually caused by depression and

occasionally by other psychiatric disorders.13,14 Depression in the

elderly can cause many of the cognitive defects that are common to

dementia.

Dementia can produce depressive signs and symptoms14 so a

misdiagnosis is relatively common. Some key differences between

dementia and depression are:6

Depression has a relatively abrupt onset but the onset of

dementia is slow.

Dementia progresses while depression plateaus.

Patients who are depressed often know they are depressed and

will complain of their problem. Patients who have dementia are

seldom aware of their condition.


The affect and emotions of people who have dementia are

variable. People who are depressed have a depressed affect and

mood.

Imaging tests, laboratory tests, and the neurological exam of a

patient who has dementia will often be abnormal; this is not the

case for patients who are depressed.

Assessment Of Dementia

Assessment and the diagnosing of

dementia can be quite challenging.

One of the primary problems in the

assessment is that the patient is

often an unreliable source of

information. Confirmation of the

diagnosis of dementia using imaging

studies, laboratory tests, and/or

specific physical findings may not be

possible. Also, some patients may

have more than one cause of

dementia. The diagnostic process is time consuming and it is not

uncommon for dementia to be mis-diagnosed.4 The incidence of a

missed diagnosis of dementia has been reported to be as high as 50%-

80%, depending on the severity of the case and who is doing the

assessment.15

The specific diagnostic approach, i.e., what tests should be ordered,

will differ depending on the suspected cause of dementia. But the

assessment process outlined below can be applied to any situation in

which dementia may be present.


Vital Signs

Assessment of the airway, breathing, and circulation (ABCs) and body

temperature is always the first step of a patient assessment.

Abnormalities of blood pressure, pulse, and temperature can provide

valuable indicators about the source of dementia. For example,

hypothermia can indicate the presence of hypothyroidism and

hypertension can indicate the possible presence of vascular dementia.

History

The events in the patient’s life prior to the assessment should be

reviewed, either by speaking to the patient, family members, friends,

or caretakers. The reviewer should ask specific questions about

behavior, changes in social circumstances, daily activities, elimination

patterns, food and fluid intake, and mood. It is important to learn

whether there have been any recent events such as an accident,

illness, trauma, or surgery that could be a cause of delirium. The

reviewer should also determine if the neuropsychological changes have

been slow or sudden in onset and how quickly they have progressed as

this information can provide valuable clues about the etiology of

dementia.16,17

Family/Significant Other Interview

A careful interview of family members/significant others and

caretakers is a necessary part of patient evaluation because the

patient who has dementia will seldom be aware of the changes in

cognition and memory. The interviewer should ask specific questions

about the patient’s day-to-day life:


Has the patient been agitated, disruptive, or verbally aggressive?

Has there been wandering behavior or dangerous driving?

Has the patient had difficulty sleeping?

Has the patient’s personal hygiene deteriorated or has he/she

been incontinent?

Galvin, et al., found that the following eight question interview was

sensitive and specific for detecting dementia and cognitive

impairment.18 Has the patient shown any of the following deficits or

behaviors?

Problems with judgment

Reduced interest in activities or hobbies

Repeating questions, stories, or statements

Trouble learning how to use an appliance or tool

Forgetting what month or year it is

Unable to handle simple financial affairs

Forgetting appointments

Consistent problems with memory and/or thinking

Medical and Surgical History

The patient’s medical and surgical history should be be carefully

reviewed. This review should include the medical history of the

patient’s immediate family, i.e., parents and siblings. Asking about

alcohol or drug abuse can be uncomfortable but it should be done;

and, it is often helpful to review the patient’s history of alcohol or drug

abuse with someone other than the patient.


Medication History

When reviewing the patient’s health history a current list of the

prescription medications the patient is taking should be obtained and

verified to know whether new medications have recently been

prescribed or doses have been changed. An inquiry should be made

about the use of over-the-counter and/or herbal medications. It should

also be determined if the patient has been taking his/her medications

as prescribed. There may have been an inadvertent or intentional

overdose, the patient may have been skipping doses, or he/she may

have simply stopped taking a prescribed medication.

Physical Assessment

A comprehensive physical examination should be performed. The

findings may be equivocal and/or non-specific, but the presence of

some physical findings and the absence of others can help the

clinician decide which diagnostic tests should be done and suggest the

cause of the dementia. For example, bradykinesia and gait

disturbances are characteristic of Parkinson’s disease, the presence of

papilledema suggests that the patient may a brain tumor or a subdural

hematoma, and myoclonus can indicate the presence of human

immunodeficiency virus (HIV)-related dementia.7

Laboratory Tests, Imaging Studies, Other Diagnostic Tools

There are no laboratory tests, imaging studies, or other diagnostic

tools that should be routinely performed for every patient who is

suspected of having dementia.4,16 The physical examination and

history taking should determine what is needed, and it is important to


focus diagnostic efforts in order to avoid unnecessary procedures and

delays in making the diagnosis.

Laboratory tests that are helpful when determining the cause or

presence of dementia include complete blood count (CBC), blood urea

nitrogen (BUN) and creatinine, serum calcium and phosphorus, pulse

oximetry, serum glucose, serum electrolytes, liver function tests,

thyroid studies, vitamin B12 level, 12-lead ECG, and (possibly) testing

for HIV antibodies.16 The American Academy of neurology suggests

that at a minimum laboratory tests for determining the cause of

dementia should include CBC, electrolytes, renal and thyroid function

studies, a vitamin B12 level, and a neuro-imaging study such as a

computerized tomography (CT) scan or a magnetic resonance imaging

(MRI) scan.16

The use of neuro-imaging studies such as CT or MRI - especially MRI -

can be used to determine the specific type of dementia, to evaluate

the progress of neurological damage, and possibly predict who will

develop dementia.16,19,20 For example, medial temporal lobe atrophy is

common in patients with dementia, but it is usually more pronounced,

and the pattern of injury different, in patients who have Alzheimer’s

disease; and, cerebral infarcts may be seen in patients who have

vascular dementia.19

Neurologic and Psychiatric Assessment

A careful assessment of the patient’s neurological and psychiatric

status is the crucial part of the evaluation for the presence of

dementia. There is much information that can be acquired by simple


observation. When the clinician is examining or interviewing the

patient, it is important to pay special attention to:7,16,17

Alertness/level of consciousness:

Whether the patient is paying attention and responding to their

surroundings

Aphasia:

Inability to express or understand language, spoken or written

Apraxia:

Inability to perform physical tasks that the patient has the

capability of doing

Behavior:

Erratic or inappropriate behavior in the patient, observed or

reported

General appearance

Memory:

How well the patient retains and recalls information

Mood:

Unexplained mood swings in the patient, observed or reported

Orientation:

Whether the patient knows the date and time

Thought process:

Organized or disorganized thinking

The clinician should also carefully observe the patient for:1

Executive functioning, i.e., planning, weighing alternatives,

coordination of mental faculties for accomplishing tasks

Insight and judgment

Memory, short-term and long-term

Use of language


Level of consciousness

Visuospatial functions, i.e., how well the patient analyzes and

understands space in several dimensions

Neurological and psychiatric functioning can also be assessed by using

neuropsychological testing and standardized screening tests.

Neuropsychological testing is a broad term that refers to tests that are

designed to assess a single neurological function such as memory,

intelligence, or visuospatial ability. For example, memory can be

tested using the Constructional Praxis Test and using the clock test can

assess visuospatial ability. Neuropsychological tests are lengthy and

complex and they can be helpful when the initial assessment shows a

cognitive deficit but the specific problem causing the cognitive deficit is

not obvious. These tests are considered to have a relatively high

sensitivity and specificity for detecting dementia,4 and can be useful in

differentiating dementia from depression.1

Standardized screening tests can be helpful to assess for the presence

and severity of dementia, but it should be remembered that these are

used for screening; they are not diagnostic nor are they a substitute

for a comprehensive mental status examination; they may not detect

early stage dementia, and; they cannot differentiate between different

types of dementia.16,17 Nonetheless, these screening tests are widely

used and a familiarity with them is important.

Five screening tests that are commonly used are the Mini-Mental State

Examination (MMSE), the Mini-Cog, The Clinical Dementia Rating

(CDR) scale, Addenbrooke’s Cognitive Examination - revised (ACE-r),


and the Montreal Cognitive Assessment (MOCA). There are many other

assessment tests/tools and a full discussion of each one and their

limits, strengths, and how and when they should be used is beyond

the scope of this module but several will be reviewed here. In depth

information on dementia screening tests is available in the 2015

review by Tsoi, et al. (2015),21 the 2014 review by Yokomizo, et al.,15

and a 2013 review by Lin, et al.22

Mini-Mental Status Exam

The Mini-Mental Status Exam (MMSE) is commonly used. It can be

done relatively quickly, and it is the most widely studied of the

cognitive screening tests.4 The test is not considered to be sensitive

for mild dementia and performance may be affected by age and level

of education.4

The MMSE involves performance of the following tasks:

What is the date: (year)(season)(date)(day)(month) - 5 points

Where are we: (state)(county)(town)(hospital)(floor) - 5 points

Name three objects:

Name three objects and then ask the patient to repeat them.

Give one point for each correct answer. Repeat them until

he/she learns all three. Count and record the number of trials.

The first repetition determines the score, but if the patient

cannot learn the words after six trials then recall cannot be

meaningfully tested: Maximum score is 3 points.


Serial 7s:

Ask the patient to count backwards in increments of 7, starting

with the number 100. One point for each correct answer; stop

after five answers. Alternatively, spell WORLD backwards, one

point for each letter in correct order: Maximum score is 5 points.

Ask for the three objects repeated above - one point for each

correct: Maximum score is 3 points.

Show and ask patient to name a pencil and wristwatch - 2

points.

Repeat the following: "No ifs, ands, or buts." Allow only one trial

- 1 point.

Follow a three stage command, "Take a paper in your right hand,

fold it in half, and put it on the floor." Score one point for each

task executed: Maximum score is 3 points.

On a blank piece of paper write "close your eyes." Then ask the

patient to read and do what it says - 1 point.

Give the patient a blank piece of paper and ask him/her to write

a sentence. The sentence must contain a noun and verb and be

sensible - 1 point.

Ask the patient to copy a design (i.e., intersecting pentagons).

All 10 angles must be present and two must intersect – 1 point.

The maximum score on the MMSE is 30 points. A score of less than 24

points is usually considered to be suggestive of dementia or delirium.4


Mini-Cog

The Mini-Cog test requires the patient to: 1) Draw a clock with the

numbers in correct sequence and the clock hands correctly indicating

the current time; and, 2) Perform an uncued recall of three objects.

The names of the three objects (i.e., banana, car, dog) are given to

the patient and he/she is then asked to repeat them. After that, the

patient is asked to draw the clock and when that task has been

completed, he/she is asked to tell the interviewer the names of the

three objects. Each correctly recalled word is worth one point and the

clock is considered normal if the time is correct and the clock is grossly

normal.

Dementia is present if the score is 0 or if the patient recalls 1-2 words

and the clock is abnormal. If the patient recalls 1-2 words and the

clock is normal or if the patient recalls all 3 words, there is no

dementia. The Mini-Cog is very quick to administer. It takes

approximately three minutes to complete and it is considered to be

very sensitive for detecting dementia.4

Clinical Dementia Rating

The Clinical Dementia Rating (CDR) was designed to assess the

severity of Alzheimer’s disease. It is rather lengthy to administer and it

depends to a degree on the subjective observations of the test

administrator, but it has been shown to be valid and sensitive.4

The patient’s abilities in the following areas are assessed when using

the CDR.


Community affairs

Home and hobbies

Judgment

Memory

Orientation

Problem solving

The patient is judged on his/her abilities and performances in these

areas as follows:

0 = None

0.5 = Very mild

1 = Mild

2 = Moderate

3 = Severe

The ratings and interpretations are:

0 = Normal

0.5 to 4 = Questionable cognitive impairment

4.5 to 9 = Mild dementia

9.5 to 15.5 = Moderate dementia

≥ 16 = Severe dementia

Montreal Cognitive Assessment (MOCA)

The Montreal Cognitive Assessment (MOCA) has been shown to be a

useful screening tool for detecting MCI and detecting MCI in patients

who have Alzheimer’s disease,23,24 for identifying people with cognitive

impairment who are at risk for developing dementia,25 and identifying

patients who have dementia.26,27 The patient is assessed in 10 areas of

cognitive ability, i.e., attention, memory, and sentence repetition and


the test takes approximately 10 minutes to administer. A complete

example of the MOCA will not be presented here, as it is quite lengthy;

and, the reader is recommended to pursue additional information

online at the mocatest.org website.

Assessment Of Delirium

In many cases delirium is a clinical diagnosis that cannot be confirmed

by imaging studies, laboratory tests, or specific physical findings and

determining whether the patient does, or does not have delirium will

depend on thorough history taking and patient assessment. The

assessment process outlined below can be applied to any situation in

which delirium may be present.

Vital Signs

Assessment of the airway, breathing, and circulation (ABCs), and body

temperature is always the first step of a patient assessment. Hypo-

and hyperthermia, hypoxia, hyper- and hypotension, bradycardia,

tachycardia, respiratory depression and tachypnea can be signs of

causes of delirium. Some causes of delirium include blood loss,

congestive heart failure, dehydration, drug overdose, infection, and

myocardial infarction.

History

The events in the patient’s life prior to the onset of delirium should be

reviewed, either by speaking to the patient, family members, friends,

or caretakers. The clinician should ask specific questions about

behavior, changes in social circumstances, daily activities, elimination

patterns, food and fluid intake, and mood. It is important to learn


whether there have been any recent events such as an accident,

illness, trauma, or surgery that could be a cause of delirium.

Medical and Surgical History

The patient’s medical and surgical history should be carefully

reviewed. This review should include the medical history of the

patient’s immediate family, i.e., parents and siblings. Similar to the

history taking with dementia, the history should include a thorough

investigation into the patient’s use or abuse of substances. Since

she/he may not be forthcoming or unable to inform the interviewer

about the history of substance abuse, it may be necessary to ask

someone other than the patient about the patient’s use of alcohol

and/or illicit drugs.

Medication History

A current list of the prescription medications the patient is taking and

verification of new medications recently prescribed or changes in

dosing is important. The clinician should inquire about the use of over-

the-counter and/or herbal medications. It is important to determine if

the patient has been taking his or her medications as prescribed.

There may have been an inadvertent or intentional overdose, the

patient may have been skipping doses, or he or she may have simply

stopped taking a prescribed medication.

Physical Assessment

A physical examination can be difficult or impossible to perform if the

patient is agitated, confused, or uncooperative. If it is not possible to

do a complete physical examination then the clinician should do a


partial examination in stages and gather as much information as

possible by observing the patient.

Findings from a physical examination in situations where the patient

may be unable to cooperate may be equivocal. However, the presence

of some physical findings and the absence of others can help the

clinician decide which diagnostic tests should be done and can suggest

the cause of the delirium. For example, the patient who has had a

stroke may have hemiparesis or a patient who is dehydrated will have

dry mucous membranes and decreased skin turgor.

Laboratory Testing, Imaging Studies, Other Diagnostic Tools

There are no laboratory tests, imaging studies, or other diagnostic

tools that should be routinely performed for every patient who is

suspected of having delirium. The physical examination and history

taking should determine what is needed, and it is important to focus

diagnostic efforts in order to avoid unnecessary procedures and delays

in making the diagnosis.

Basic tests that are helpful when assessing for the presence of delirium

are the CBC, creatinine, serum calcium, electrolytes, and glucose,

arterial blood gas, 12-lead ECG, and urinalysis and urine culture. Drug

levels of medications such as digoxin and lithium should be done if

appropriate. Neuro-imaging should be done if there is no obvious

cause of delirium.8


Neurological and Psychiatric Assessment

As with the physical examination, a complete neurological and

psychiatric evaluation may not be possible if the patient is agitated,

confused, or uncooperative. When evaluating a patient for the

presence of delirium, carefully observe these areas of cognition and

behavior:1,8

Executive functioning, i.e., planning, weighing alternatives

General appearance and behavior

Insight and judgment

Memory, short-term and long-term

Language

Level of consciousness

Orientation

Language

Mood and affect

Thought content

Visuospatial functions, i.e., how well the patient analyzes and

understands space in several dimensions

The signs and symptoms of delirium include:1,8

Agitation

Anxiety

Apathy

Delusions

Difficulty with language and speech

Disorientation

Distractibility

Drowsiness


Dysarthria

Dysphasia

Emotional lability

Flight of ideas

Fluctuating level of consciousness

Hallucinations

Illusions

Inability to concentrate or focus

Memory loss

Perceptual disturbances

Restlessness

Sleep disturbances

Tremor

Standardized screening tests can be used to detect delirium. One of

the oldest and most commonly used in the Confusion Assessment

Method (CAM).8 The CAM has been shown to be accurate and

reliable.8,28 It is easy to administer and it can be used in a wide variety

of clinical situations but it does require considerable training to use

correctly.28

The CAM compares well to other delirium screening tests, but it should

be remembered that no screening test is perfect for detecting

delirium.29,30

The CAM has two parts: the first is an assessment tool that is used to

detect cognitive impairment and the second is a short screening test

that is used to distinguish delirium from dementia. Part two is


presented here, in Table 5. The diagnosis of delirium by CAM requires

the presence of features 1 and 2 and either 3 or 4.31

Table 5: The CAM Screening Test Part 2

1. Acute onset and fluctuating course

Is there evidence of an acute change in mental status from the

patient’s baseline?

Did the abnormal behavior fluctuate during the day, i.e., tend to come

and go, or increase and decrease in severity)?

2. Inattention

Did the patient have difficulty focusing attention (i.e., being easily

distractible) or have difficulty keeping track of what was being said?

3. Disorganized thinking

Was the patient’s thinking disorganized or incoherent? Did he/she have

rambling or irrelevant conversation, unclear or illogical flow of ideas, or

unpredictable switching from subject to subject?

4. Altered level of consciousness

How would you rate this patient’s level of consciousness? Alert

(normal), vigilant (hyper-alert), lethargic (drowsy, easily aroused),

stuporous (difficult to arouse), or coma (unarousable). If the patient’s

level of consciousness is anything other than alert, that should be

considered a positive score.


Nursing Care Of The Patient With Dementia

Nursing care and treatment of the patient who has dementia should

focus on:

Communication

Neuropsychiatric behavioral issues

Safety and comfort

Pain Control

Medication used to treat dementia

Communication

The patient who has Alzheimer’s disease, vascular dementia, or any

pathology that causes dementia will have problems in using and

understanding language. The patient may have difficulty

understanding what is said, expressing ideas and emotions, and

responding appropriately.32 Hearing and speech impairments may be

present and depression may negatively influence the patient’s desire

to communicate.

Limitations of the patient with

dementia do not mean the patient

needs to be isolated or that the

nurse cannot have clear and

meaningful communication with

the patient. The keys to

overcoming limitations are

assessment and adjustment.


The nurse caring for the dementia patient needs to assess the patient’s

communication abilities and needs and then adjust to his or her

communication style. If the nurse can do this, the interactions

between the nurse and the patient will be effective and satisfying. This

is done on an individual basis but there are some simple principles the

nurse should always keep in mind when communicating with a patient

who has dementia.

Communication problems associated with dementia do not

correspond to a loss of self-identity and studies show that the

personality endures despite these communication difficulties.33,34

When a caregiver acknowledges a patient’s self-identity, the

patient’s disruptive and combative behavior is often dissipated.

The challenge for caregivers is to discover the patient’s self-

identity.

Families and caregivers develop effective personalized

communication patterns with patients35 and it can be very

helpful to ask them how they communicate with the patient.

Reality orientation is a helpful communication strategy. It

involves constant, repetitive verbal and visual clues to keep the

patient oriented. This technique can improve functional abilities

in patients who have dementia.36,37 Potential scenarios would be

that the nurse introduces themself each time they talk to the

patient, points to calendars and clocks frequently in

conversation, and talks about current events and the plans for

the day.


Speaking clearly and slowly is important in the facilitation of

meaningful and successful conversation with the patient who has

dementia. Remember to make eye contact and use short

sentences. Waiting for responses and not answering for the

patient is another helpful strategy; avoid finishing sentences for

the patient or interrupting the patient.

If the patient cannot answer or respond correctly at first, the

nurse should try again. Being aware of one’s tone and volume of

voice and of body language is important. Minimizing distractions

when communicating with the patient with dementia and

avoiding several conversations at the same time will help the

patient’s effort to communicate.

The Alzheimer’s Association publishes a guideline on

communicating with patients who have dementia that outlines

some of these strategies (accessible at alzheimers.org).

Neuropsychiatric Behavioral Problems

Neuropsychiatric behavior problems are a common and serious

complication of dementia.38-40 Agitation, aggression, anxiety, apathy,

delusions, depression, disinhibition, hallucinations, inappropriate

behavior, sleep disturbances, and wandering occur quite often and

they are disturbing for patients and caregivers. They are also

potentially dangerous and if not properly managed, they can increase

the incidence of morbidity and mortality and increase length of

hospital stay.


It is often assumed that these problems are simply part of dementia

and dementia does contribute to their development, their intensity and

how and when they occur. However, the cause of and initiating factors

for agitation, aggression, inappropriate actions and speech, and other

neuropsychiatric behavioral problems is almost always internal and/or

external stimuli that are not obvious to family members, caregivers,

and health care professionals.41

The patient who has dementia frequently has cognitive deficits that

affect his or her ability to cope, communicate, and provide self-care,

and neuropsychiatric behavior problems are simply a response to

stress. It is important for the caregiver or clinician to evaluate

stressors and the patient’s response to stressors. Considering

neuropsychiatric behavior problems as “normal” for a patient who has

dementia is in one sense treating the patient as less than whole.

It is recommended that behavioral and environmental approaches

should be used to treat neuropsychiatric behavior problems before

pharmacological intervention.38,42,43 Medications should only be used in

these situations if:

Non-pharmacologic interventions have failed.

The patient has major depression with or without suicidal

ideation.

The patient has a psychosis that is causing great harm or has

the potential to do so.

The patient is very aggressive and may harm himself/herself or

others.


DICE Method

The optimal approach to neuropsychiatric behavior problems can be

summarized as making every effort to understand the situation from

the patient’s point of view. A recommended method is the DICE

approach: Describe, Investigate, Create and Evaluate.44 This is a

systematic way of identifying and treating neuropsychiatric behavior

problems that operates with the assumption that such behavior

problems are caused by a stressor that can be identified and

corrected and that these issues can be solved with creativity and

patience.

Describe

In the first step of the DICE method the clinician is exploring such

questions as:

When is the patient agitated and where is he or she when this

behavior is happening?

Who was the patient interacting with or near to when the

agitation occurred?

What are the environmental conditions, the time of day?

What was the patient doing immediately before the agitation

began?

Is the patient complaining and if so, about what?

Investigate

In this step the clinician is looking for cause, by investigating such

questions as:

Was the patient recently given a medication or is he or she

scheduled for a dose?


Was the patient recently started on a medication?

Has the patient been incontinent or could he or she be in pain?

Has the patient’s daily activity schedule been changed or his or

her sleep pattern been disrupted?

What are the patient’s vital signs?

When performing this investigation it is important to remember that

many people who have dementia are elderly and have chronic medical

problems. Neuropsychiatric behavioral problems are often caused by

emotional or psychological stress, but the possibility of an acute illness

or exacerbation of an existing one should always be considered.

Create

Creating a treatment plan should be a collaborative effort between

nurses, other healthcare professionals and if they are involved in day-

to-day care, the family members. The clinician needs to focus on the

behavior that is problematic at the time, but also on root cause and

prevention. Strategies for the two can be different. The patient who is

agitated may need to be in a place that is quiet and away from others

- an immediate solution - but underlying causes such as over-

stimulation and pain need to be addressed.

Evaluate

In this final step, the clinician is evaluating the strategy in terms of

negative and positive consequences and how easy it was to apply.


Safety And Comfort Of The Patient With Dementia

Safety and comfort are very important areas of care. The patient who

has dementia has a decreased capacity for decision making and may

also have limited physical capabilities. Those factors increase the risk

for accidents, errors in judgment, falls, and other forms of harm.

Discomfort is a common source of behavioral problems for the patient

who has dementia. He or she may be unable to communicate about

discomfort or take actions to relieve discomfort and this can lead to

behavioral problems such as agitation or wandering. Assessment and

re-assessment of the patient and his or her environment must be done

frequently, and the clinician should always be evaluating whether the

patient is safe and comfortable.

Pain Control

Pain is very common in patients who have dementia and it is often

under-recognized and under treated.45-47 Patients who have dementia

do not experience any less pain than older adults without dementia,

but assessment for pain in this patient population is challenging.

Patients who have dementia may not interpret sensations as painful,

have difficulty recalling pain in the recent past, and may be unable to

tell someone about their pain. In addition, the patient who has

dementia may be prescribed analgesics, antipsychotics, or other

medications that can blunt their response to pain. Untreated pain can

cause behavioral problems and psychological distress,45 and untreated

pain in any patient is unacceptable.


In many patient care situations assessment for the presence of pain

and evaluating the success of treatments for pain depends in large

part on self-reporting: the patient will tell us how much pain he or she

is having and if the interventions provided relief. But for the patient

who has dementia this is often not an option. Nurses and other

healthcare professionals will need to use professional judgment and an

assessment tool.

There are many pain assessment tools available, but it is not clear

which ones are best for this clinical application. Recent reviews by

Corbett, et al. (2014) and Husebo, et al. (2016; 2014; 2010) of pain

assessment tools utilized when assessing patients with dementia noted

that the Mobilization-Observation-Behavior-Intensity-Dementia-2

(MOBID-2) pain assessment tool is useful and reliable45,47-49 and the

MOBID-2 has “... high-to-excellent reliability and aspects of

validity”.45

The MOBID-2 is very reliable for detecting the presence of pain in

patients who have dementia and could also be used to assess the

response to pain treatments.45 The MOBID-2 uses the patient’s

observed responses (facial expression, aversive/defensive behavior,

and noises indicating the presence of pain) to five simple physical

tasks, i.e., stretching both arms towards the head; and, observations

by the nurse or other caregiver of patient behavior during normal daily

activities that may indicate the presence of pain.49

The choice of pain medication should be guided by the clinical

situation. There are few controlled studies that have assessed the use

of analgesics for this patient population. Husebo, et al. (2016)


reviewed the available literature and found the evidence was strongest

for the use of acetaminophen; there was very little data on the use of

opioids; and, there are no controlled studies on the use of codeine,

non-steroidal anti-inflammatories, or tramadol.47

Medications Used to Treat Dementia

Non-pharmacologic treatments should be the first line therapies for

treating patients who have dementia and have behavioral issues such

as agitation and anxiety but these may not always be effective. The

primary drugs that are used to treat problematic behaviors in this

patient population are the cholinesterase inhibitors and memantine.

The drugs most commonly used to treat dementia are the

cholinesterase inhibitors.50,51 The three cholinesterase inhibitors

currently available in the U.S., that have a labeled use for the

treatment of dementia of Alzheimer’s disease are donepezil,

galantamine, and rivastigmine. Cholinesterase inhibitors inhibit the

activity of cholinesterase at the synaptic cleft and increase cholinergic

transmission. Patients who have Alzheimer’s disease have a decreased

cerebral synthesis of acetylcholine, but the cholinesterase inhibitors

are also used to treat vascular dementia, Lewy body disease,

frontotemporal dementia, and other forms of dementia.

The cholinesterase inhibitors can produce a mild improvement in

cognition and increase the ability to perform activities of daily living,

and they may delay progression of cognitive defects.50 The long-term

benefits of the use of cholinesterase inhibitors for patients who have

dementia is still being determined, and it is not known which patients

who have dementia should be prescribed these drugs and what the


optimum duration of therapy is.50 Regardless, most sources

recommend a trial period of cholinesterase inhibitors and donepezil,

galantamine, or rivastigmine can be used; they appear to be equally

effective.50 The dose should be slowly titrated and at the end of eight

weeks of the maximum dose the patient should be reassessed. If there

is no improvement, the drug should be stopped.50

Donepezil, galantamine, and rivastigmine are available as oral tablets,

solution, sustained-release capsules, and transdermal patch. Because

of their mechanism of action, gastrointestinal effects such as diarrhea,

nausea, and vomiting are very common. Agitation, ataxia, dizziness,

headache are also common adverse effects.

Memantine is an N-methyl-D-aspartate (NMDA) receptor antagonist. N-

methyl-D-aspartate is a neurotransmitter that mimics the action of

glutamate, one of the major excitatory neurotransmitters. Memantine

has a labeled use for the treatment of moderate to severe dementia

associated with Alzheimer’s disease and an unlabeled use for the

treatment of mild to moderate vascular dementia. Used alone or with

cholinesterase inhibitors, memantine helps improve cognition and

performance of activities of daily living, and it may slow progression of

the disease.52 Common adverse reactions effects of memantine include

confusion, dizziness, and headache. The drug is available as oral

tablets, solution, and extended-release capsules.

The use of antipsychotics for treating behavioral problems associated

with dementia is somewhat controversial. Brasure, et al., in their 2016

review write that the antipsychotic medications “... have limited

efficacy and significantly increase the risk of stroke and mortality. For


some individuals with dementia, side effects of antipsychotic

medications can lower quality of life.”38 Greenblatt, et al. (2016)

however note that the conventional and atypical antipsychotics

“... appear to have modest to moderate clnical efficacy in the

treatment of these symptoms.”53 Both of these authors acknowledge

the increased risk of mortality associated with the use of

antipsychotics in this patient population but the opinion of the risk by

Greenblatt, et al., appears tempered: “... the observed risk increase

may be partially confounded by illness severity and/or preexisting

health determinants”.53 However, Greenblatt, et al., do caution that

the dose and duration of therapy of these drugs should be minimized

and that patients shhould be continuously monitored for adverse

effects.

Press and Alexander (2016) point out that the antipsychotics do not

have a labeled use for treating behavioral disorders in patients with

dementia, and their preference is to administer these drugs only if the

patient is having severe behavioral problems and other approaches or

medications are not effective.54

The benzodiazepines may seem to be a logical choice for treating

behavioral problems associated with dementia, but they should not be

routinely used in these clinical situations.55 There is limited evidence

for their benefit and the adverse effects and risks of their use are

considerable.54,55

Depression is best treated with a selective serotonin reuptake

inhibitor.54 These drugs should be used cautiously for patients who

have dementia however, and there is little evidence of their efficacy


for treating depression in patients who have dementia.56-58 Other

medications that have been used to treat patients who have dementia,

either for symptomatic relief or as preventative measures include:

estrogen, folic acid, gabapentin, gingko biloba, lamotrigine, melatonin,

metylphenidate non-steroidal anti-inflammatories, selegiline, statins,

trazodone, valproate, vitamin B6, vitamin B12, and vitamin E.1,54 At this

time, there is either no evidence or very limited evidence that any of

these drugs, supplements, or vitamins are effective.1,54

Other Therapies and Interventions

Cognitive rehabilitation, formalized exercise programs, and

occupational therapy are relatively risk-free interventions that have

been shown to be of benefit for patients who have dementia.42

Delirium: A Medical Emergency

Delirium is considered to be a medical emergency. Therapies and

interventions that would be appropriate when treating most patients

who have delirium would be:59,60

Hydration

Assess the level of stimulation. Under- and over-stimulation can

be a problem for patients who have delirium.

Re-orientation techniques

Bedside sitter

If possible and if it helps, close contact with a family member or

someone familiar to the patient is encouraged.

Make sure the patient has his or her corrective lenses and/or

hearing aid if they use these.

Maintain normal sleep patterns.

Assess for and treat pain.


Non-pharmacologic interventions should always be the first-line choice

for patients who have delirium.59 Physical restraints should not be

used unless other interventions have failed and there is risk to the

patient or others.59 Antipsychotics can be used to treat severe

agitation in patients who have delirium, but they do have significant

side effects and there is little data that supports their use for the

treatment of delirium.59

The standard pharmacological therapy for treating patients who have

delirium and who do not respond to non-pharmacological interventions

is haloperidol.59 Haloperdiol and the atypical antipsychotics olanzapine,

quetiapine, risperidone ziprasidone have all been shown to be effective

in treating delirium.59-61 Drowsiness, hypotension, and extrapyramidal

effects are common adverse effects of the antipsychotics.

Benzodiazepines are useful if the delirium is caused by alcohol or drug

withdrawal,59 but in other types of delirium they may worsen the

patient’s confusion and cause sedation.

Summary

Dementia and delirium are neurological disorders that cause signficant

cognitive impairment and increase the risk of morbidity and mortality.

These diseases can be difficult to detect and diagnose. Some cases of

dementia and many cases of delirium are reversible, but dementia is

most often chronic, progressive, and cannot be cured; and, the

dementias and deliriums that are considered reversible may result in

serious complications. The most common cause of dementia is

Alzheimer’s disease. Medications and dementia appear to be the most

common causes of delirium.


Advanced age itself is not a cause of either disease, but the elderly do

have a high risk for developing dementia and delirium and as the U.S.,

population continues to get older, the incidences of dementia and

delirium are likley to increase. Treatment of dementia and delirium is

primarily symptomatic and supportive unless there is a clearly

identified etiology. Primary concerns when providing nursing care for

the patient who has either dementia or delirium are: monitoring of

vitals signs, behavioral and environmental interventions, safety and

comfort, pain control, and safe administration of medications.

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b. severe agitation. c. reversible cognitive impairment.

d. occurrence before age 50.


a. trauma and heavy metal poisoning. b. infections and hemorrhage.

c. Alzheimer’s disease and vascular pathologies. d. hypoxia and Parkinson’s disease.


a. movement disorders and a progressive cognitive decline. b. attention deficits and confusion.

c. expressive aphasia and hypotension. d. hyperthermia and depression.


a. acute.

b. slow. c. chronic.

d. fluctuating.


a. Parkinson’s disease and advanced age.

b. drug withdrawal and Lewy body dementia. c. acute blood loss and frontotemporal dementia.

d. drugs and dementia.

6. True or False: Dementia is an inevitable consequence of aging.

a. True

b. False


7. The onset of neurologic changes of dementia are usually

a. acute.

b. slow and progressive. c. chronic.

d. fluctuating and regressive.

8. Use physical restraints with patients who have dementia

a. if the patient is agitated or confused. b. when there is a significant risk for a fall.

c. if all other interventions fail and there is a serious risk of harm.

d. if the patient is likely to wander.

9. Neuropsychiatric behavior problems in patients who have

dementia

a. are caused by an external or internal stimulus. b. typically occur randomly and without cause.

c. only occur if patients are over-medicated. d. happen primarily at night.

10. The use of antipsychotics for treating patients who have

dementia

a. is considered first-line therapy. b. is most effective when used in conjunction with cholinesterase

inhibitors. c. can reverse the progress of dementia.

d. is questionably effective and potentially dangerous.

11. The drug most commonly used to treat agitation in patients

who have delirium is

a. diazepam. b. haloperidol.

c. galantmine. d. bupropion.


12. True or False: Physical restraints are the first-choice

therapy for treating patients who have delirium.

a. True b. False

13. Benzodiazepines are

a. the first-line treatment for dementia or delirium.

b. absolutely contraindicated for dementia or delirium. c. seldom useful and may worsen dementia or delirium.

d. only useful if used together with antipsychotics.

14. Which of the following is commonly used to treat dementia?

a. Fluvoxamine. b. Lithium.

c. Methylphenidate. d. Rivastigmine.

15. Which of the following is commonly used to treat

dementia?

a. Memantine. b. Nortriptyline.

c. Carbamazepine. d. Diphenhydramine.

16. Dementia is a syndrome because the signs and symptoms

of dementia

a. are specific to a single age group.

b. cannot be eliminated or cured. c. can have many different causes.

d. is a major cognitive disorder.


17. The Diagnostic and Statistical Manual of Mental Disorders,

fifth edition, (DSM-5) has replaced the term dementia with the term

a. major/mild cognitive disorder.

b. major/minor cognitive deficit. c. dementia syndrome.

d. neurocognitive syndrome.

18. Cognitive deficits do not occur exclusively in the context of delirium with respect to which of the following syndromes?

a. Only with major cognitive disorder

b. With major or mild cognitive disorder c. When mental illness (e.g., schizophrenia) is not present

d. Only with minor cognitive disorder

19. Dementia can be usefully divided into two categories:

a. dementia syndrome and senior dementia.

b. unspecified and specified. c. cognitive disorder and cognitive deficit.

d. reversible and irreversible.

20. True or False: Most cases of dementia are irreversible.

a. True b. False

21. Which of the following is NOT able to cause irreversible

dementia?

a. Degenerative diseases of the nervous system

b. Trauma c. Vascular disorders

d. None of the above

22. In most cases, dementia caused by _______________ is reversible but not always.

a. carbon monoxide poisoning

b. aging c. a drug

d. hypoxia


23. Drugs that can cause dementia and delirium include:

a. alcohol.

b. anti-arrhythmics. c. skeletal muscle relaxers.

d. All of the above

24. Alzheimer’s disease is seen in the characteristic ___________________ in the parietal and temporal lobes.

a. lesions

b. protein deposits c. destruction of dopamine-producing cells

d. thrombotic obstructions

25. Frontotemporal lobe dementia is a neurodegenerative

disease caused by _____________ the frontal and temporal lobe.

a. thrombotic obstructions of

b. atrophy of c. protein deposits in

d. All of the above

26. ____________________ is a chronic, progressive neurodegenerative disease that is characterized by the

presence of abnormal deposits of protein that accumulate in neurons in specific areas of the brain.

a. Lewy body dementia

b. Frontotemporal lobe dementia

c. Parkinson’s disease d. Vascular dementia

27. Patients who have dementia often suffer from

neuropsychiatric problems such as

a. language impairment. b. arrhythmias.

c. agitation. d. hypoxia.


28. True or False: In dementia patients, there is typically no

disturbance of consciousness: the patient is awake, alert, and responsive.

a. True

b. False

29. In Alzheimer’s disease, lesions in the parietal and temporal lobes

a. interrupt the normal metabolism of neurons.

b. interrupt self-repair of neurons. c. disrupt communication between different areas of the brain.

d. All of the above

30. When making the diagnosis of ____________ it must be

specified if it is hyperactive, hypoactive, or involves a mixed level of activity.

a. Parkinson’s disease

b. vasculitis c. dementia

d. delirium

31. ___________ is an acute change in mental status characterized by confusion and disturbances in cognition.

a. Hypoxia

b. Vasculitis c. Dementia

d. Delirium

32. Parkinson’s disease’s characteristic motor symptoms are

similarly found with __________________ patients.

a. Lewy body dementia b. Alzheimer’s disease

c. frontotemporal dementia d. vascular dementia


33. Lewy body dementia is distinguished from other types of

dementia by

a. thrombotic obstructions. b. behavioral and speech defects.

c. visual hallucinations. d. expressive and fluent aphasia.

34. The hallmark signs of frontotemporal dementia are

a. visual hallucinations.

b. Parkinsonian motor signs. c. behavioral and speech defects.

d. bradykinesia and tremors.

35. With Alzheimer’s disease, the time from diagnosis to death

can be as little as

a. seven years. b. 10 years.

c. five years. d. three years.

36. True or False: Smoking is a significant risk factor for the

development of vascular dementia.

a. True b. False

37. ______________________ (a 10-minute test to

administer) has been shown to be a useful screening tool

for detecting mild cognitive impairment (MCI) and detecting MCI in patients who have Alzheimer’s disease,

and dementia, and who are at risk for developing dementia.

a. The Montreal Cognitive Assessment (MOCA)

b. The Mini-Cog test c. The Clinical Dementia Rating (CDR)

d. The ABC test


38. Depression in the elderly can cause many of the cognitive

defects that are common to

a. delirium. b. dementia.

c. Parkinsonian motor signs. d. normal aging.

39. Mild cognitive impairment is a term used to describe

cognitive deficits that are

a. a normal part of aging. b. fit into the diagnostic criteria for dementia.

c. in an intermediate state between normal cognitive functioning and dementia.

d. All of the above

40. True or False: It is well established that advanced age

itself is a risk factor for delirium.

a. True b. False

41. In many cases, delirium is

a. confirmed by laboratory tests.

b. confirmed by imaging studies. c. confirmed through specific physical findings.

d. a clinical diagnosis.

42. When delirium is suspected, the first step of a patient

assessment includes

a. neuro-imaging to confirm whether delirium is present. b. urinalysis and urine culture.

c. a 12-lead ECG. d. assessment of the airway, breathing, and circulation (ABCs).


43. One of the oldest and most commonly used standardized

screening tests used to detect delirium is

a. the Confusion Assessment Method (CAM). b. the Mini-Cog test

c. the Clinical Dementia Rating (CDR) d. the ABC test

44. The CAM has two parts: the first is an assessment tool that

is used to detect cognitive impairment and the second is a short screening test that is used

a. to distinguish delirium from drug usage.

b. to distinguish delirium from dementia. c. to identify Parkinsonian motor signs.

d. to diagnose Alzheimer’s disease.

45. In addition to assessing a patient’s airway, breathing, and

circulation (ABCs), the first step of a patient assessment for delirium includes

a. a complete blood test (CBC).

b. a urinalysis and urine culture. c. taking the patient’s body temperature.

d. neuro-imaging to confirm whether delirium is present.

46. True or False: When communicating with a patient who has dementia, a nurse should avoid finishing sentences for the

patient or interrupting the patient.

a. True

b. False

47. When a caregiver acknowledges a patient’s ___________ the patient’s disruptive and combative behavior is often

dissipated.

a. self-identity b. condition

c. limitations d. inability to communicate


48. A nurse introduces herself to the patient each time she

talks to the patient, points to calendars and clocks frequently in conversation, and talks about current events:

this is an example of a. acknowledging the patient’s self-identity.

b. recognizing limitations.

c. an inability to communicate.

d. reality orientation.

49. Successful conversation with the patient who has dementia involves

a. making eye contact.

b. using short sentences. c. speaking clearly and slowly.

d. All of the above

50. It is recommended that dementia patients with neuropsychiatric behavior problems be treated

a. only if the patient is a danger to himself or others. b. first using pharmacological intervention.

c. first using behavioral and environmental approaches. d. if the patient has concomitant delirium.

51. True or False: Neuropsychiatric behavior problems are

normal for a patient who has dementia and a nurse should accept it as part of the patient experience.

a. True

b. False

52. A recommended method for identifying and treating neuropsychiatric behavior problems in dementia patients is

known as

a. the DICE Method.

b. the Confusion Assessment Method (CAM). c. the Montreal Cognitive Assessment (MOCA).

d. the Mini-Cog.


53. The ____________________________________ is very

reliable for detecting the presence of pain in patients who have dementia and could also be used to assess the

response to pain treatments.

a. DICE Method b. Confusion Assessment Method (CAM)

c. Montreal Cognitive Assessment (MOCA) d. Mobilization-Observation-Behavior-Intensity-Dementia-2

(MOBID-2).

54. The drugs most commonly used to treat dementia are

a. antipsychotics. b. cholinesterase inhibitors.

c. benzodiazepines.

d. All of the above

55. The DICE Method operates with the assumption that neuropsychiatric behavior problems in dementia patients

are caused by

a. reality disorientation. b. dementia.

c. a stressor. d. delirium.

56. When treating dementia, the dose of cholinesterase

inhibitors should be slowly titrated and at the end of ___________ of the maximum dose the patient should be

reassessed.

a. one month

b. eight weeks c. one week

d. six months

57. If there is no improvement for the dementia patient at the end of the trial of doing with cholinesterase inhibitors,

a. the drug should be stopped.

b. drug dosing should be increased. c. drug treatment should be continued until improvement is seen.



58. True or False: The benzodiazepines may seem to be a

logical choice for treating behavioral problems associated with dementia, but they should not be routinely used in

these clinical situations.

a. True b. False

CORRECT ANSWERS:




b. Alzheimer’s disease and vascular pathologies.


b. attention deficits and confusion.


a. acute.


c. drugs and dementia.

6. True or False: Dementia is an inevitable consequence of aging.

b. False

7. The onset of neurologic changes of dementia are usually

b. slow and progressive.


8. Use physical restraints with patients who have dementia

c. if all other interventions fail and there is a serious risk of

harm.

9. Neuropsychiatric behavior problems in patients who have dementia

a. are caused by an external or internal stimulus.

10. The use of antipsychotics for treating patients who have

dementia

d. is questionably effective and potentially dangerous.

11. The drug most commonly used to treat agitation in patients

who have delirium is

b. haloperidol.

12. True or False: Physical restraints are the first-choice therapy for treating patients who have delirium.

b. False

13. Benzodiazepines are

c. seldom useful and may worsen dementia or delirium.


dementia?

d. Rivastigmine.


dementia?

a. Memantine.

16. Dementia is a syndrome because the signs and symptoms of dementia

c. can have many different causes.


17. The Diagnostic and Statistical Manual of Mental Disorders,

fifth edition, (DSM-5) has replaced the term dementia with the term

a. major/mild cognitive disorder.

18. Cognitive deficits do not occur exclusively in the context of

delirium with respect to which of the following syndromes?

b. With major or mild cognitive disorder

19. Dementia can be usefully divided into two categories:

d. reversible and irreversible.

20. True or False: Most cases of dementia are irreversible.

a. True

21. Which of the following is NOT able to cause irreversible

dementia?


22. In most cases, dementia caused by _______________ is reversible but not always.

c. a drug

23. Drugs that can cause dementia and delirium include:

d. All of the above

24. Alzheimer’s disease is seen in the characteristic ___________________ in the parietal and temporal lobes.

a. lesions

25. Frontotemporal lobe dementia is a neurodegenerative

disease caused by _____________ the frontal and temporal lobe.

b. atrophy of


26. ____________________ is a chronic, progressive

neurodegenerative disease that is characterized by the presence of abnormal deposits of protein that accumulate

in neurons in specific areas of the brain.


27. Patients who have dementia often suffer from neuropsychiatric problems such as

c. agitation.

28. True or False: In dementia patients, there is typically no

disturbance of consciousness: the patient is awake, alert, and responsive.

a. True

29. In Alzheimer’s disease, lesions in the parietal and temporal lobes

d. All of the above

30. When making the diagnosis of ____________ it must be

specified if it is hyperactive, hypoactive, or involves a mixed level of activity.

d. delirium

31. ___________ is an acute change in mental status

characterized by confusion and disturbances in cognition.

d. Delirium

32. Parkinson’s disease’s characteristic motor symptoms are

similarly found with __________________ patients.


33. Lewy body dementia is distinguished from other types of dementia by

c. visual hallucinations.


34. The hallmark signs of frontotemporal dementia are

c. behavioral and speech defects.

35. With Alzheimer’s disease, the time from diagnosis to death

can be as little as

d. three years.

36. True or False: Smoking is a significant risk factor for the development of vascular dementia.

a. True

37. ______________________ (a 10-minute test to

administer) has been shown to be a useful screening tool

for detecting mild cognitive impairment (MCI) and detecting MCI in patients who have Alzheimer’s disease,

and dementia, and who are at risk for developing dementia.

a. The Montreal Cognitive Assessment (MOCA)

38. Depression in the elderly can cause many of the cognitive

defects that are common to

b. dementia.

39. Mild cognitive impairment is a term used to describe cognitive deficits that are

c. in an intermediate state between normal cognitive functioning and dementia.

40. True or False: It is well established that advanced age

itself is a risk factor for delirium.

b. False

41. In many cases, delirium is

d. a clinical diagnosis.


42. When delirium is suspected, the first step of a patient

assessment includes

d. assessment of the airway, breathing, and circulation (ABCs).

43. One of the oldest and most commonly used standardized screening tests used to detect delirium is

a. the Confusion Assessment Method (CAM).

44. The CAM has two parts: the first is an assessment tool that

is used to detect cognitive impairment and the second is a short screening test that is used

b. to distinguish delirium from dementia.

45. In addition to assessing a patient’s airway, breathing, and circulation (ABCs), the first step of a patient assessment

for delirium includes

c. taking the patient’s body temperature.

46. True or False: When communicating with a patient who has dementia, a nurse should avoid finishing sentences for the

patient or interrupting the patient.

a. True

47. When a caregiver acknowledges a patient’s ___________ the patient’s disruptive and combative behavior is often

dissipated.

a. self-identity

48. A nurse introduces herself to the patient each time she

talks to the patient, points to calendars and clocks frequently in conversation, and talks about current events:

this is an example of

d. reality orientation.


49. Successful conversation with the patient who has dementia

involves

d. All of the above

50. It is recommended that dementia patients with neuropsychiatric behavior problems be treated

c. first using behavioral and environmental approaches.

51. True or False: Neuropsychiatric behavior problems are

normal for a patient who has dementia and a nurse should accept it as part of the patient experience.

b. False

52. A recommended method for identifying and treating neuropsychiatric behavior problems in dementia patients is

known as

a. the DICE Method.

53. The ____________________________________ is very reliable for detecting the presence of pain in patients who

have dementia and could also be used to assess the response to pain treatments.

d. Mobilization-Observation-Behavior-Intensity-Dementia-2

(MOBID-2).

54. The drugs most commonly used to treat dementia are

b. cholinesterase inhibitors.

55. The DICE Method operates with the assumption that

neuropsychiatric behavior problems in dementia patients are caused by

c. a stressor.


56. When treating dementia, the dose of cholinesterase

inhibitors should be slowly titrated and at the end of ___________ of the maximum dose the patient should be

reassessed.

b. eight weeks

57. If there is no improvement for the dementia patient at the end of the trial of doing with cholinesterase inhibitors,

a. the drug should be stopped.

58. True or False: The benzodiazepines may seem to be a

logical choice for treating behavioral problems associated with dementia, but they should not be routinely used in

these clinical situations.

a. True

References Section

The reference section of in-text citations include published works

intended as helpful material for further reading. Unpublished works

and personal communications are not included in this section, although

may appear within the study text.

1. Kane RL, Ouslander JG, Abrass IB, Resnick B. Dementia and

delirium. Essentials of Clinical Geriatrics. 7th ed. New York, NY:

McGraw-Hill; 2013. Online edition. Accessed September 25, 2014

from www.UCHC.edu.

2. Fiest KM, Roberts JI, Maxwell CJ, et al. The prevalence and

incidence of dementia due to Alzheimer's disease: a systematic

review and meta-analysis. Can J Neurol Sci. 2016;43(Suppl

1):S51-S82.

http://www.uchc.edu/

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Fiest%20KM%5BAuthor%5D&cauthor=true&cauthor_uid=27307128

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Roberts%20JI%5BAuthor%5D&cauthor=true&cauthor_uid=27307128

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Maxwell%20CJ%5BAuthor%5D&cauthor=true&cauthor_uid=27307128

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/27307128


3. Centers for Disease Control and Prevention. Alzheimer’s Disease.

July 25, 2104.

http://www.cdc.gov/aging/aginginfo/alzheimers.htm. Accessed

August 8. 2016.

4. Larson EB. Evaluation of cognitive impairment and dementia.

UpToDate. October 28, 2015. From

http://www.uptodate.com/contents/evaluation-of-cognitive-

impairment-and-

dementia?source=search_result&search=dementia&selectedTitle=

1%7E150. Accessed August 7, 2016.

5. Cole MG, Mccusker J. Delirium in older adults: a chronic cognitive

disorder? Int Psychogeriatr. 2016;28(8):1229-1233.

6. American Psychiatric Association. Major and mild neurocognitive

disorders. In: Diagnostic and Statistical Manual of Mental

Disorders, Fifth ed. Alexandria, VA: American Psychiatric

Association; 2013.

7. Greenberg DA, Aminoff MJ, Simon RP. Dementia & Amnestic

Disorders. Clinical Neurology, 8th ed. New York, NY: McGraw-

Hill;2012. Accessed September 25, 2014 from www. UCHC.edu.

8. Francis J, Young, GB. Diagnosis of delirium and acute confusional

states. UpToDate. August 22, 2014.

http://www.uptodate.com/contents/diagnosis-of-delirium-and-

confusional-

states?source=search_result&search=Delirium+and+acute&select

edTitle=2%7E150. Accessed August 8, 2016.

9. American Psychiatric Association. Delirium. Diagnostic and

Statistical Manual of Mental Disorders, 5th ed. Arlington, VA:

American Psychiatric Publishing; 2013.

10. Langa KM, Levine DA. The diagnosis and management of mild

cognitive impairment: a clinical review. JAMA. 2014;

312(23):2551-2561

11. McDade EN, Petersen RN. Mild cognitive impairment:

epidemiology, pathology, and clinical assessment. UpToDate,

October 30, 2015. http://www.uptodate.com/contents/mild-

cognitive-impairment-epidemiology-pathology-and-clinical-

assessment?source=search_result&search=mild+cognitive+impai

rment&selectedTitle=1%7E56. Accessed August 8, 2016.

http://www.cdc.gov/aging/aginginfo/alzheimers.htm

http://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia?source=search_result&search=dementia&selectedTitle=1%7E150




http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Cole%20MG%5BAuthor%5D&cauthor=true&cauthor_uid=27246118

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Mccusker%20J%5BAuthor%5D&cauthor=true&cauthor_uid=27246118


http://www.uptodate.com/contents/diagnosis-of-delirium-and-confusional-states?source=search_result&search=Delirium+and+acute&selectedTitle=2%7E150




http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Langa%20KM%5BAuthor%5D&cauthor=true&cauthor_uid=25514304

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Levine%20DA%5BAuthor%5D&cauthor=true&cauthor_uid=25514304


http://www.uptodate.com/contents/mild-cognitive-impairment-epidemiology-pathology-and-clinical-assessment?source=search_result&search=mild+cognitive+impairment&selectedTitle=1%7E56





12. Sachdev PS, Lipnicki DM, Crawford J, et al. Factors predicting

reversion from mild cognitive impairment to normal cognitive

functioning: a population-based study. PLoS One.

2013;(3):e59649. doi: 10.1371/journal.pone.0059649. Epub

2013 Mar 27.

13. Fisman M. Pseudo-dementia. Prog Neuropsychopharmaco Bio

Psychiatry. 1985;9(5-6):481-484

14. Kang H, Zhao F, You L, et al. Pseudo-dementia: A

neuropsychological review. Ann Indian Acad Neurol.

2014;17(2):147-154.

15. Yokomizo JE, Simon SS, de Campos Bottino CM. Cognitive

screening for dementia in primary care: a systematic review. Intl

Psychogeriatr. 2014;26(11):1783-1804.

16. Seeley WW, Miller BL. Dementia. In: Longo DL, Fauci AS, Kasper

DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles

of Internal Medicine, 19th ed. New York, NY: McGraw-Hill; 2015.

On line edition. Accessed August 8, 2016 from www.UCHC.edu.

17. Grossman M, Irwin DJ. The mental status examination in patients

with suspected dementia. Continuum (Minneap Minn)

2016;22(2):385--403.

18. Galvin JE, Roe CM, Xiong X, Morris JC. Validity and reliability of

the ADB informant interview in dementia. Neurology.

2006;67(11):1942-1948.

19. Mortimer M, Likeman M, Lewis TT. Neuroimaging in dementia: a

practical guide. Practl Neurol. 2013;13(2):92-103.

20. Kanev T, Sablosky M, Vento J, O’Hanlon D. Structural and

functional neuro-imaging methods in the diagnosis of dementia: A

retrospective chart and brain imaging review. Neurocase.

2012;18(3):224-234.

21. Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cognitive tests to

detect dementia: A systematic review and meta-analysis. JAMA

Intern Med. 2015;175(9):1450-1458.

22. Lin JS, O'Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening

for cognitive impairment in older adults: A systematic review for

the US Preventive Services Task Force. Ann Intern Med.

2013;159(9):601-612.

23. Freitas S, Simões MR, Alves L, Santana I. Montreal cognitive

assessment: validation study for mild cognitive impairment and

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Sachdev%20PS%5BAuthor%5D&cauthor=true&cauthor_uid=23544083

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Lipnicki%20DM%5BAuthor%5D&cauthor=true&cauthor_uid=23544083

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Crawford%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23544083


http://www.ncbi.nlm.nih.gov/pubmed/3911280


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Kang%20H%5BAuthor%5D&cauthor=true&cauthor_uid=25024563

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Zhao%20F%5BAuthor%5D&cauthor=true&cauthor_uid=25024563

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=You%20L%5BAuthor%5D&cauthor=true&cauthor_uid=25024563

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Yokomizo%20JE%5BAuthor%5D&cauthor=true&cauthor_uid=25023857

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Simon%20SS%5BAuthor%5D&cauthor=true&cauthor_uid=25023857

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=de%20Campos%20Bottino%20CM%5BAuthor%5D&cauthor=true&cauthor_uid=25023857

http://www.uchc.edu/

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Tsoi%20KK%5BAuthor%5D&cauthor=true&cauthor_uid=26052687

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Chan%20JY%5BAuthor%5D&cauthor=true&cauthor_uid=26052687

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Hirai%20HW%5BAuthor%5D&cauthor=true&cauthor_uid=26052687

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Wong%20SY%5BAuthor%5D&cauthor=true&cauthor_uid=26052687

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Kwok%20TC%5BAuthor%5D&cauthor=true&cauthor_uid=26052687



http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Lin%20JS%5BAuthor%5D&cauthor=true&cauthor_uid=24145578

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=O'Connor%20E%5BAuthor%5D&cauthor=true&cauthor_uid=24145578

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Rossom%20RC%5BAuthor%5D&cauthor=true&cauthor_uid=24145578

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Perdue%20LA%5BAuthor%5D&cauthor=true&cauthor_uid=24145578

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Eckstrom%20E%5BAuthor%5D&cauthor=true&cauthor_uid=24145578

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Freitas%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22193353

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Sim%C3%B5es%20MR%5BAuthor%5D&cauthor=true&cauthor_uid=22193353

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Alves%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22193353

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Santana%20I%5BAuthor%5D&cauthor=true&cauthor_uid=22193353


Alzheimer disease. Alzheimer Dis Assoc Disord. 2013; 27(1):37-

43.

24. O'Caoimh R, Timmons S, Molloy DW. Screening for mild cognitive

impairment: Comparison of "MCI Specific" screening instruments.

J Alzheimers Dis. 2016;51(2):619-629.

25. Lam B, Middleton LE, Masellis M, Stuss DT, Harry RD, Kiss A.

Criterion and convergent validity of the Montreal Cognitive

Assessment with screening and standardized neuropsychological

testing. J Amer Geriatr Soc. 2013;61(12):2181-2185.

26. Dong Y, Lee WY, Basri NA, et al. The Montreal Cognitive

Assessment is superior to the Mini-Mental State Examination in

detecting patients at higher risk of dementia. Int Psychogeriatr.

2012; 24(11):1749-1755.

27. Wang CS, Pai MC, Chen PL, Hou NT, Chien PF, Huang YC.

Montreal Cognitive Assessment and Mini-Mental State

Examination performance in patients with mild-to-moderate

dementia with Lewy bodies, Alzheimer's disease, and normal

participants in Taiwan. Int Psychogeriatr. 2013;25(11):1839-

1845.

28. Han JH, Wilson A, Graves AJ, Shintani A, Schnelle JF, Ely EW. A

quick and easy delirium assessment for nonphysician research

personnel. Am J Emerg Med. 2016;34(6):1031-1036.

29. Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient

have delirium?: value of bedside instruments. JAMA 2010;

304(7):779-786.

30. Hendry K, Quinn TJ, Evans J, et al. Evaluation of delirium

screening tools in geriatric medical inpatients: a diagnostic test

accuracy study. Age Ageing. 2016 Aug 8. [Epub ahead of print]

31. Waszynski CM. Confusion Assessment Method (CAM). Try This:

Best Practices in Nursing Care to Older Adults. The Hartford

Institute for Geriatric Nursing. 2001;November, Issue 13.

32. Veselinova C. Influencing communication and interaction in

dementia. Nursing & Residential Care. 2014;16(3):162-166.

33. Skaalvik MW, Fjelltun AM, Normann HK, Norberg A. Expressions

of sense of self among individuals With Alzheimer's disease. Res

Theory Nurs Pract. 2016;30(2):161-175.

34. O’Connell B, Gardner A, Takase M, et al. Clinical usefulness and

feasibility of using reality orientation with patients who have


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=O%27Caoimh%20R%5BAuthor%5D&cauthor=true&cauthor_uid=26890758

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Timmons%20S%5BAuthor%5D&cauthor=true&cauthor_uid=26890758

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Molloy%20DW%5BAuthor%5D&cauthor=true&cauthor_uid=26890758


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Lam%20B%5BAuthor%5D&cauthor=true&cauthor_uid=24320735

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Middleton%20LE%5BAuthor%5D&cauthor=true&cauthor_uid=24320735

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Masellis%20M%5BAuthor%5D&cauthor=true&cauthor_uid=24320735

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Stuss%20DT%5BAuthor%5D&cauthor=true&cauthor_uid=24320735

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Harry%20RD%5BAuthor%5D&cauthor=true&cauthor_uid=24320735

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Kiss%20A%5BAuthor%5D&cauthor=true&cauthor_uid=24320735

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Dong%20Y%5BAuthor%5D&cauthor=true&cauthor_uid=22687278

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Lee%20WY%5BAuthor%5D&cauthor=true&cauthor_uid=22687278

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Basri%20NA%5BAuthor%5D&cauthor=true&cauthor_uid=22687278

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Wang%20CS%5BAuthor%5D&cauthor=true&cauthor_uid=23919950

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Pai%20MC%5BAuthor%5D&cauthor=true&cauthor_uid=23919950

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Chen%20PL%5BAuthor%5D&cauthor=true&cauthor_uid=23919950

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Hou%20NT%5BAuthor%5D&cauthor=true&cauthor_uid=23919950

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Chien%20PF%5BAuthor%5D&cauthor=true&cauthor_uid=23919950

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Huang%20YC%5BAuthor%5D&cauthor=true&cauthor_uid=23919950

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Han%20JH%5BAuthor%5D&cauthor=true&cauthor_uid=27021131

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Wilson%20A%5BAuthor%5D&cauthor=true&cauthor_uid=27021131

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Graves%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=27021131

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Shintani%20A%5BAuthor%5D&cauthor=true&cauthor_uid=27021131

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Schnelle%20JF%5BAuthor%5D&cauthor=true&cauthor_uid=27021131

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Ely%20EW%5BAuthor%5D&cauthor=true&cauthor_uid=27021131


http://www.uptodate.com/contents/diagnosis-of-delirium-and-confusional-states/abstract/28



http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Hendry%20K%5BAuthor%5D&cauthor=true&cauthor_uid=27503794

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Quinn%20TJ%5BAuthor%5D&cauthor=true&cauthor_uid=27503794

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Evans%20J%5BAuthor%5D&cauthor=true&cauthor_uid=27503794


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Skaalvik%20MW%5BAuthor%5D&cauthor=true&cauthor_uid=27333635

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Fjelltun%20AM%5BAuthor%5D&cauthor=true&cauthor_uid=27333635

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Normann%20HK%5BAuthor%5D&cauthor=true&cauthor_uid=27333635

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Norberg%20A%5BAuthor%5D&cauthor=true&cauthor_uid=27333635




dementia in acute care settings. Int J Nurs Pract.

2007;13(3):182-192.

35. Miller C. Communication difficulties in hospitalized older adults

with dementia. Am J Nurs. 2008;108(3):59-66.

36. Dourado MC, Laks J. Psychological interventions for

neuropsychiatric disturbances in mild and moderate Alzheimer's

disease: Current evidences and future directions. Curr Alzheimer

Res. 2016 Jul 28. [Epub ahead of print]

37. Camargo CH, Justus FF, Retzlaff G. The effectiveness of reality

orientation in the treatment of Alzheimer's disease. Am J

Alzheimers Dis Other Demen. 2015;30(5):527-532.

38. Brasure M, Jutkowitz E, Fuchs E, Nelson VA, Kane RA, Shippee T,

Fink HA, Sylvanus T, Ouellette J, Butler M, Kane RL.

Nonpharmacologic Interventions for Agitation and Aggression in

Dementia. Comparative Effectiveness Review No. 177. (Prepared

by the Minnesota Evidence-based Practice Center under Contract

No. 290-2012-00016-I.) AHRQ Publication No.16-EHC019-EF.

Rockville, MD: Agency for Healthcare Research and Quality; March

2016. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

Accessed August 1, 2016.

39. Dourado MC, Laks J. Psychological interventions for

neuropsychiatric disturbances in mild and moderate Alzheimer's

disease: Current evidences and future directions. Curr Alzheimer

Res. 2016 Jul 28. [Epub ahead of print]

40. Mitoku K, Shimanouchi S. The decision-making and

communication capacities of older adults with dementia: A

population-based study. The Open Nurs J: 2014;8:17-24.

41. Rabins, PV, Blass DM. In the clinic: Dementia. Ann Int Med. 2014;

161(3):ITC1. doi:10.7326/0003-4819-161-3-201408050-01002.

42. Kales HC. Common sense: Addressed to geriatric psychiatrists on

the subject of behavioral and psychological symptoms of

dementia. Am J Geriatr Psychiatry. 2015;23(12):1209-1213.

43. Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of

behavioral and psychological symptoms of dementia. BMJ. 2015

Mar 2;350:h369. doi: 10.1136/bmj.h369.

44. Kales HC, Gitlin LN, Lyketsos CG; Detroit Expert Panel on

Assessment and Management of Neuropsychiatric Symptoms of

Dementia. Management of neuropsychiatric symptoms of

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Laks%20J%5BAuthor%5D&cauthor=true&cauthor_uid=27468911



http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Camargo%20CH%5BAuthor%5D&cauthor=true&cauthor_uid=25588408

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Justus%20FF%5BAuthor%5D&cauthor=true&cauthor_uid=25588408

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Retzlaff%20G%5BAuthor%5D&cauthor=true&cauthor_uid=25588408



http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Dourado%20MC%5BAuthor%5D&cauthor=true&cauthor_uid=27468911

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Laks%20J%5BAuthor%5D&cauthor=true&cauthor_uid=27468911



http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Kales%20HC%5BAuthor%5D&cauthor=true&cauthor_uid=26705691


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Kales%20HC%5BAuthor%5D&cauthor=true&cauthor_uid=25731881

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Gitlin%20LN%5BAuthor%5D&cauthor=true&cauthor_uid=25731881

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Lyketsos%20CG%5BAuthor%5D&cauthor=true&cauthor_uid=25731881




dementia in clinical settings: recommendations from a

multidisciplinary expert panel. J Am Geriatr Soc. 2014;

62(4):762-769.

45. Corbett A, Husebo BS, Achterberg WP, Aarsland D, Erdal A, Flo E.

The importance of pain management in older people with

dementia. Br Med Bull. 2014;111(1):139-148.

46. Chandler RC, Zwakhalen SM, Docking R, Bruneau B, Schofield P.

Attitudinal & knowledge barriers towards effective pain

assessment & management in dementia: A narrative synthesis.

Curr Alzheimer Res. 2016 Jun 2. [Epub ahead of print]

47. Husebo BS, Achterberg W, Flo E. Identifying and managing pain in

people with Alzheimer's disease and other types of dementia: A

systematic review. CNS Drugs. 2016;30(6):481-497.

48. Husebo BS, Ostelo R, Strand LI. The MOBID-2 pain scale:

reliability and responsiveness to pain in patients with dementia.

Eur J Pain. 2014;18(10):1419-1430.

49. Husebo BS, Strand LI, Moe-Nilssen R, Husebo SB, Ljunggren AE.

Pain in older persons with severe dementia. Psychometric

properties of the Mobilization-Observation-Behaviour-Intensity-

Dementia (MOBID-2) Pain Scale in a clinical setting. Scan J Caring

Sci. 2010;24(2):380-391.

50. Press D, Alexander M. Cholinesterase inhibitors in the treatment

of dementia. UpToDate. December 11, 2015.

https://remote.uchc.edu/Citrix/UConnHealthWeb/clients/HTML5Cli

ent/src/SessionWindow.html?launchid=1471023199589. Accessed

August 12, 2016.

51. Campos C, Rocha NB, Vieira RT, et al. Treatment of cognitive

deficits in Alzheimer's disease: A psychopharmacological review.

Psychiatr Danub. 2016;28(1):2-12.

52. Deardorff WJ, Grossberg GT. Pharmacotherapeutic strategies in

the treatment of severe Alzheimer's disease. Expert Opin

Pharmacother. 2016; 29:1-12.

53. Greenblatt HK, Greenblatt DJ. Use of antipsychotics for the

treatment of behavioral symptoms of dementia. J Clin Pharmacol.

2016 Mar 7. doi: 10.1002/jcph.731. [Epub ahead of print]

54. 55. Press D, Alexander M. Management of neuropsychiatric

symptoms of dementia. UpToDate. June 6, 2016.

https://www.uptodate.com/contents/management-of-



http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Corbett%20A%5BAuthor%5D&cauthor=true&cauthor_uid=25190763

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Husebo%20BS%5BAuthor%5D&cauthor=true&cauthor_uid=25190763

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Achterberg%20WP%5BAuthor%5D&cauthor=true&cauthor_uid=25190763

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Aarsland%20D%5BAuthor%5D&cauthor=true&cauthor_uid=25190763

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Erdal%20A%5BAuthor%5D&cauthor=true&cauthor_uid=25190763

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Flo%20E%5BAuthor%5D&cauthor=true&cauthor_uid=25190763

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Chandler%20RC%5BAuthor%5D&cauthor=true&cauthor_uid=27335047

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Zwakhalen%20SM%5BAuthor%5D&cauthor=true&cauthor_uid=27335047

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Docking%20R%5BAuthor%5D&cauthor=true&cauthor_uid=27335047

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Bruneau%20B%5BAuthor%5D&cauthor=true&cauthor_uid=27335047

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Schofield%20P%5BAuthor%5D&cauthor=true&cauthor_uid=27335047


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Husebo%20BS%5BAuthor%5D&cauthor=true&cauthor_uid=27240869

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Achterberg%20W%5BAuthor%5D&cauthor=true&cauthor_uid=27240869

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Flo%20E%5BAuthor%5D&cauthor=true&cauthor_uid=27240869


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Husebo%20BS%5BAuthor%5D&cauthor=true&cauthor_uid=20210897

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Strand%20LI%5BAuthor%5D&cauthor=true&cauthor_uid=20210897

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Moe-Nilssen%20R%5BAuthor%5D&cauthor=true&cauthor_uid=20210897

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Husebo%20SB%5BAuthor%5D&cauthor=true&cauthor_uid=20210897

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed?term=Ljunggren%20AE%5BAuthor%5D&cauthor=true&cauthor_uid=20210897

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Pain+in+older+persons+with+severe+dementia.+Psychometric+properties+of+the+Mobilization%E2%80%93Observation%E2%80%93Behaviour%E2%80%93Intensity%E2%80%93Dementia+(MOBID-2)+Pain+Scale+in+a+clinical+setting.

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Pain+in+older+persons+with+severe+dementia.+Psychometric+properties+of+the+Mobilization%E2%80%93Observation%E2%80%93Behaviour%E2%80%93Intensity%E2%80%93Dementia+(MOBID-2)+Pain+Scale+in+a+clinical+setting.

https://remote.uchc.edu/Citrix/UConnHealthWeb/clients/HTML5Client/src/SessionWindow.html?launchid=1471023199589

https://remote.uchc.edu/Citrix/UConnHealthWeb/clients/HTML5Client/src/SessionWindow.html?launchid=1471023199589

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Campos%20C%5BAuthor%5D&cauthor=true&cauthor_uid=26938815

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Rocha%20NB%5BAuthor%5D&cauthor=true&cauthor_uid=26938815

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Vieira%20RT%5BAuthor%5D&cauthor=true&cauthor_uid=26938815


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Deardorff%20WJ%5BAuthor%5D&cauthor=true&cauthor_uid=27450461

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Grossberg%20GT%5BAuthor%5D&cauthor=true&cauthor_uid=27450461



http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Greenblatt%20HK%5BAuthor%5D&cauthor=true&cauthor_uid=26953213

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Greenblatt%20DJ%5BAuthor%5D&cauthor=true&cauthor_uid=26953213


https://www.uptodate.com/contents/management-of-neuropsychiatric-symptoms-of-dementia


neuropsychiatric-symptoms-of-dementia. Accessed August 13,

2016.

55. Defrancesco M, Marksteiner J, Fleischhacker WW, Blasko I. Use of

benzodiazepines in Alzheimer's disease: A systematic review of

literature. Int J Neuropsychopharmacol. 2015 May

19;18(10):pyv055. doi: 10.1093/ijnp/pyv055.

56. Puranen A, Taipale H, Koponen M, et al. Incidence of

antidepressant use in community-dwelling persons with and

without Alzheimer's disease: 13-year follow-up. Int J Geriatr

Psychiatry. 2016 Feb 28. doi: 10.1002/gps.4450. [Epub ahead of

print]

57. Laitinen ML, Lönnroos E, Bell JS, Lavikainen P, Sulkava R,

Hartikainen S. Use of antidepressants among community-dwelling

persons with Alzheimer's disease: a nationwide register-based

study. Int Psychogeriatr. 2015;27(4):669-672.

58. Sepehry AA, Lee PE, Hsiung GY, Beattie BL, Jacova C. Effect of

selective serotonin reuptake inhibitors in Alzheimer's disease with

comorbid depression: a meta-analysis of depression and cognitive

outcomes. Drugs Aging. 2012;29(10):793-806.

59. Francis J. Delirium and acute confusional states: Prevention,

treatment, and prognosis. UpToDate. August 13, 2014.

http://www.uptodate.com/contents/delirium-and-acute-

confusional-states-prevention-treatment-and-prognosis. Accessed

August 8, 2016.

60. Balas MC, Rice M, Chaperon C, Smith H, Disbot M, Fuchs B.

Management of delirium in critically ill older adults. Critl Care

Nurse. 2012;32(4):15-26.

61. Yoon HJ, Park KM, Choi WJ, et al. Efficacy and safety of

haloperidol versus atypical antipsychotic medications in the

treatment of delirium. BMC Psychiatry. 2013 Sep 30;13:240. doi:

10.1186/1471-244X-13-240.

https://www.uptodate.com/contents/management-of-neuropsychiatric-symptoms-of-dementia

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Defrancesco%20M%5BAuthor%5D&cauthor=true&cauthor_uid=25991652

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Marksteiner%20J%5BAuthor%5D&cauthor=true&cauthor_uid=25991652

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Fleischhacker%20WW%5BAuthor%5D&cauthor=true&cauthor_uid=25991652

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Blasko%20I%5BAuthor%5D&cauthor=true&cauthor_uid=25991652


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Puranen%20A%5BAuthor%5D&cauthor=true&cauthor_uid=26924266

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Taipale%20H%5BAuthor%5D&cauthor=true&cauthor_uid=26924266

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Koponen%20M%5BAuthor%5D&cauthor=true&cauthor_uid=26924266



http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Laitinen%20ML%5BAuthor%5D&cauthor=true&cauthor_uid=25412711

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=L%C3%B6nnroos%20E%5BAuthor%5D&cauthor=true&cauthor_uid=25412711

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Bell%20JS%5BAuthor%5D&cauthor=true&cauthor_uid=25412711

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Lavikainen%20P%5BAuthor%5D&cauthor=true&cauthor_uid=25412711

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Sulkava%20R%5BAuthor%5D&cauthor=true&cauthor_uid=25412711

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Hartikainen%20S%5BAuthor%5D&cauthor=true&cauthor_uid=25412711


http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Sepehry%20AA%5BAuthor%5D&cauthor=true&cauthor_uid=23079957

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Lee%20PE%5BAuthor%5D&cauthor=true&cauthor_uid=23079957

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Hsiung%20GY%5BAuthor%5D&cauthor=true&cauthor_uid=23079957

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Beattie%20BL%5BAuthor%5D&cauthor=true&cauthor_uid=23079957

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Jacova%20C%5BAuthor%5D&cauthor=true&cauthor_uid=23079957

http://www-ncbi-nlm-nih-gov.online.uchc.edu/pubmed/?term=Sepehry+AA%2C+Lee+PE%2C+Hsiung+GY%2C+et+al.+Effect+of+selective+serotonin+reuptake+inhibitors+in+Alzheimer%27s+disease+with+comorbid+depression%3A+a

http://www.uptodate.com/contents/delirium-and-acute-confusional-states-prevention-treatment-and-prognosis

http://www.uptodate.com/contents/delirium-and-acute-confusional-states-prevention-treatment-and-prognosis

http://www.ncbi.nlm.nih.gov/pubmed?term=Balas%20MC%5BAuthor%5D&cauthor=true&cauthor_uid=22855075

http://www.ncbi.nlm.nih.gov/pubmed?term=Rice%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22855075

http://www.ncbi.nlm.nih.gov/pubmed?term=Chaperon%20C%5BAuthor%5D&cauthor=true&cauthor_uid=22855075

http://www.ncbi.nlm.nih.gov/pubmed?term=Smith%20H%5BAuthor%5D&cauthor=true&cauthor_uid=22855075

http://www.ncbi.nlm.nih.gov/pubmed?term=Disbot%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22855075

http://www.ncbi.nlm.nih.gov/pubmed?term=Fuchs%20B%5BAuthor%5D&cauthor=true&cauthor_uid=22855075

http://www.ncbi.nlm.nih.gov/pubmed?term=Yoon%20HJ%5BAuthor%5D&cauthor=true&cauthor_uid=24074357

http://www.ncbi.nlm.nih.gov/pubmed?term=Park%20KM%5BAuthor%5D&cauthor=true&cauthor_uid=24074357

http://www.ncbi.nlm.nih.gov/pubmed?term=Choi%20WJ%5BAuthor%5D&cauthor=true&cauthor_uid=24074357



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