Lec 4 Delirium Dementia

DELIRIUM & DEMENTIA

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Confusion in the Elderly

Confusion is usually a symptom of delirium or dementia patient may have both

RAC

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Delirium or Dementia?Analogy courtesy of Stefan Kowalski

DementiaDelirium

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Assessing Cognitive Function

Useful to assess and document

severity of cognitive impairment

measure changes in cognitive function over time

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Delirium

An acute or subacute deterioration in mental functioning that occurs commonly in the older population cause is usually multifactorial and reversible

RAC

GP

Med

ical

car

e of

old

er p

erso

ns in

res

iden

tial a

ged

care

fac

ilitie

s (4

th e

ditio

n)

plus

or

and

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DeliriumPrecipitating Factors

RAC

GP

Med

ical

car

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old

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erso

ns in

res

iden

tial a

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care

fac

ilitie

s (4

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Anticholinergic drugsDiuretics

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RAC

GP

Med

ical

car

e of

old

er p

erso

ns in

res

iden

tial a

ged

care

fac

ilitie

s (4

th e

ditio

n)

possibly drug induced


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Managing Delirium

NICE clinical guideline 103: Delirium Diagnosis, prevention and management (2010)

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Delirium ManagementTreat Precipitating Factors

RAC

GP

Med

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car

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old

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iden

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care

fac

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As per Theory 1

Review need for potential contributing

medications

Diuretics


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Delirium Precipitating FactorsAnticholinergic Drugs

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Delirium ManagementAcute Management of Delusions and Hallucinations

Ther

apeu

tic G

uide

lines

: Psy

chot

ropi

c,ve

rsio

n 6

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Acute Management of Delusions and Hallucinations

Risks

Risks to be discussed in

schizophrenia

Ther

apeu

tic G

uide

lines

: Psy

chot

ropi

c,ve

rsio

n 6

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Assessment and Management of Delirium

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Acute or Chronic

Identify and treat underlying

cause

Short term management of agitation if necessary

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Dementia

Onset ≥ 65yo

Onset < 65yo

ALZHEIMER'S AUSTRALIA (2005) DEMENTIA ESTIMATES AND PROJECTIONS: AUSTRALIAN STATES AND TERRITORIES

Pract Neurol 2009;9:241-251

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Dementia


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Alzheimer’s Disease Natural History

Alzheimer’s disease: symptomatic drugs under development. In: Gauthier S, ed. Clinical Diagnosis and Management of Alzheimer’s Disease. Boston, MA: Butterworth-Heinemann; 1996:239-259.

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Alzheimer’s Disease Natural History

Euro

pean

Jou

rnal

of

Neu

rolo

gy 1

998.

Vol

S (s

uppl

4)

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Alzheimer’s DiseaseAdditional Cognitive Assessment Tools

Alzheimer’s disease: symptomatic drugs under development. In: Gauthier S, ed. Clinical Diagnosis and Management of Alzheimer’s Disease. Boston, MA: Butterworth-Heinemann; 1996:239-259.

ADAS‐CogAlzheimer’s Dementia Assessment Scale ‐ CognitiveA more extensive assessment tool developed specifically for Alzheimer’s DiseaseScore‐: 0‐70 (higher scores worse)Improvement ≥4 considered clinically significant

CIBIC (±carer)Clinician's Interview-Based Impression of Change

Subjective overview of general patient functioning, cognition, behaviour and activities of daily livingScore: 1‐7 (very much improved ‐ very much worse)

Limitations other than Alzheimer’s to completing MMSE

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Management of Dementia

Prevent progression not possible for Alzheimer's Disease

Improve cognitive function Manage behavioural disturbances Reduce carer burden

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Management of Vascular (Multi-infarct) Dementia


Address stroke risk factors

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Management of Alzheimer’s Disease

Ther

apeu

tic G

uide

lines

: Psy

chot

ropi

c,ve

rsio

n 6

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Don

epez

ilRi

vast

igm

ine

Gal

anta

min

e

Cholinesterase InhibitorsBenefit: Cognitive Improvement

Ann

als

of G

ener

al H

ospi

tal P

sych

iatr

y 20

03, 2

:1

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Cholinesterase InhibitorsBenefits: Improvement in MMSE

The

Coc

hran

e Li

brar

y 20

12, I

ssue

5

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Benefit: Improvement in MMSEDonepezil v Rivastigmine

The

Coc

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brar

y 20

12, I

ssue

5

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Alzheimer’s DiseaseAChEI do not treat underlying cause

N E

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200

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1:56

-67

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Cholinesterase InhibitorsBenefits: Improvement in MMSE

Am

J P

sych

iatr

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07;1

64:8

49-8

52.

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Cholinesterase InhibitorsOld PBS Restriction: Initial Supply

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Cholinesterase InhibitorsOld PBS Restriction: Initial Supply

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Cholinesterase InhibitorsOld PBS Restriction: Continuing Tx

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Review of PBS Anti-dementia Drugs32

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Cholinesterase InhibitorsCurrent PBS Restriction: Continuing Tx

Cholinesterase InhibitorsBenefits: Activities of Daily Living

The

Coc

hran

e Li

brar

y 20

12, I

ssue

5

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Cholinesterase InhibitorsBenefits: Behavioural Disturbance

The

Coc

hran

e Li

brar

y 20

12, I

ssue

5

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Cholinesterase InhibitorsBenefits: Carer Input

The

Coc

hran

e Li

brar

y 20

12, I

ssue

5

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Benefits: Behavioural DisturbanceDonepezil v Rivastigmine

The

Coc

hran

e Li

brar

y 20

12, I

ssue

5

39

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Cholinesterase InhibitorsCurrent PBS Restriction: Continuing Tx

Cholinesterase InhibitorsRisks

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Cholinesterase InhibitorsRisks: Withdrawal due to adverse effect

The

Coc

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e Li

brar

y 20

12, I

ssue

5

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Risks: Withdrawal due to adverse effectDonepezil v Rivastigmine (oral)

Nausea Vomiting

Anorexia Diarrhoea

The Cochrane Library 2012, Issue 5

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Cholinesterase InhibitorsManaging Risks

Start low and uptitrate after 4 weeksRivastigmine patch

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Management of Alzheimer’s Disease

Therapeutic Guidelines: Psychotropic, version 6

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MemantineBenefits: ADAS-Cog

Mild

(MM

SE 2

0-23

)M

oder

ate

(MM

SE 1

0-19

)

Arch Neurol. 2011;68(8):991-998

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MemantinePBS Restriction: Initial Supply

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MemantineRisks

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Donepezil plus Memantine

JAMA. 2004 Jan 21;291(3):317-24

Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus) scale

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Management of Behavioural Disturbances


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Management of Behavioural DisturbancesRisks

Risks to be discussed in schizophrenia and Parkinson’s disease

Risks to be discussed in anxiety


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Management of Behavioural DisturbancesRisks


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Management of Behavioural DisturbancesRisks – Cerebrovascular Adverse Events

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Management of Behavioural DisturbancesRisks – Cerebrovascular Adverse Events

CNS Drugs 2005; 19 (2): 91-103

Serious CVAE: defined as death, life-threatening, requiring hospitalisation or leading to persistent disability

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Management of Behavioural DisturbancesRisks – Managing Cerebrovascular Adverse Events

CNS Drugs 2005; 19 (2): 91-103Serious CVAE: defined as death, life-threatening, requiring hospitalisation or leading to persistent disability

Non-drug techniquesUse lowest dose required

Limit duration of treatment (<12 weeks)

Minimise drug exposure

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Management of Behavioural DisturbancesFactors that contribute to behavioural disturbances

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Non-drug techniques for behavioural disturbances

Education explanation for residents and relatives/carers, training of RACF staff

Sensory stimulation orientation cues, diversional activities, music, massage, pets

Cognitive reminders and repetition of information

Self care skills dressing, eating, toileting

Physical activity simple exercise routines

walking, gentle exercise groups

Social interaction regular social activity, groups, and visitors

Behavioural therapies re-orientation, reminiscence

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Lec 4 Delirium Dementia

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