Dementia and Delirium

SC1 Year Lecture Programme

RCSI
 Dementia Syndrome
A syndrome due to disease of the brain,usually of a chronic
or progressive nature,in which there is disturbance of
multiple higher cortical functions,including
memory,thinking,orientation,comprehension,calculation,
learning capacity,language and
judgement.Consciousness is not clouded
Impairments of cognitive function are commonly
accompanied and occasionally preceded,by deterioration
in emotional control,social behaviour or motivation.
This syndrome occurs in Alzheimers disease,in
cerebrovascular disease and in other conditions primarily
or secondarily affecting the brain.
 How common is dementia?

Prevalence increases with age

3% in over 65s
20% in over 80s
 Dementia Syndrome
Alzheimers disease (Dr Alois Alzheimer 1906)

Degenerative disorder with characteristic clinical and

neurodegenerative features
> 50% of all dementia cases
Prevalence rises with age
5% of population over 65 years
25% of population over 80 years
In Ireland 35,000 with dementia,50% with AD.
 Alzheimers Disease
Clinical Features

Amnesia is a universal feature

Temporal and spatial orientation
Language Skills
Planning and organisational skills
Judgement and Problem solving skills
 Alzheimers Disease
Clinical Features
Associated Features :
Psychiatric Symptoms and Behavioural Disturbance
Common in up to 60%
Lack of motivation,Apathy,Loss of interest ----- Depression
Delusions,Hallucinations and Misidentifications
Behavioural Disturbance
Aggression
Wandering
Sleep Disturbance
Sexual Disinhition
Increased Eating
 Dementia
Differential diagnosis
Delirium
Pseudodementia
Vascular dementia
Lewy body dementia
Frontotemporal dementia
Alcohol induced dementia
Normal pressure hydrocephalus
Differential Diagnosis:
Recurrent /severe hypoglycaemia
Post-hypoxia
Vitamin B12 deficiency
Brain Tumours
Trauma
Infections Syphilis,HIV
 Causes of Dementia
Huntingtons Disease
Prion Dementias/CJD
Wilsons Disease
Neurosyphilis
Sarcoidosis
HIV
Subacute Sclerosing Panencephalitis
 Differential Diagnosis
Vascular Dementia
Lewy Body Dementia
Frontotemporal
Dementia associated with Parkinson's Disease
 Diagnosis
History and Collateral Information
Physical Examination
Assessment of Cognition
MMSE 30 point minimental state examination
ADAS Cog
CAMCOG
Assessment of functional level
 Dementia Syndrome
Multidisciplinary Approach
Information and Education
Investigations
Review of Medications
Medications Specific for AD
 Dementia stage of disease
Dementia is said to be
mild if a person still retains the ability to
manage independently;
moderate if some help is needed in the
ordinary tasks of living;and
severe if continual help and support is
required.
 Medications for AD
Anti Cholinesterase Drugs
Donepezil,Rivastigmine,Galantamine
Not all respond
Prevent decline in cognitive function
Side Effects
Nausea,Vomiting,Diarrhoea,Dizziness,Insomnia
Titration of dose
 Medications
All anticholinesterase inhibitors(AChEIs)
Improve cognition (ADAS cog)
Improve/Maintain Function
Effect on Behaviour
 Medications for AD
NICE Guidelines

AD with MMSE > 12/30

Specialist Clinic
Follow up and Review
 Medications for AD
MEMANTINE (Ebixa)
For moderate to severe dementia
Works by modulating effects of Glutamate via NMDA
receptor
Improvements in cognition,global assessment and function
compared with placebo
 Medications for AD
Depression
SSRI
Agitation
Short Acting Benzodiazepines Lorazepam
Neuroleptics for behavioural symptoms
Risperidone,Olanzepine,Quietiapine
 Vascular Dementia
Vascular history and risk factors
Sudden onset of cognitive deficit, early gait
disturbance, falls and pseudobulbar palsy
Clinical signs
Brain imaging
 Lewy Body Dementia
Fluctuating but progressive cognitive
impairment; episodes of confusion and lucid
intervals
Visual/Auditory hallucinations often with
secondary delusions
Parkinsonian symptoms and signs
Antipsychotic drug sensitivity
 Delirium
Delirium is characterised by a disturbance of
consciousness and a change in cognition that develops
over a short period of time.The disorder has a tendency to
fluctuate during the course of the day,and there is evidence
from the history,examination or investigations that the
delirium is a direct consequence of a general medical
condition,drug withdrawal or intoxication.
 Delirium
Delirium may have more than one causal factor
History of onset and Course
Cognitive testing
At risk:
Elderly
Severely Ill
Dementia
Physically Frail
Admitted with infection or dehydration
Visually Impaired
Polypharmacy
Alcohol Excess
 Delirium
Onset short
Marked fluctuation;Lucid intervals
Altered consciousness
Poor attention
Disturbed cognition
Delusions and hallucinations
Fear,restlessness
 Delirium
CAUSES

Infection
Neurological
Cardiological
Respiratory
Electrolyte imbalance
Endocrine and metabolic
Drugs
Multiple causes
 Delirium

Full History
Clinical Examination
Investigations
Treatment of Underlying Cause
Management of Confusion
Environment
Drugs
Prevention of complications
 Delirium
Complications
Falls
Pressure Sores
Nosocomial Infections
Functional Impairment
Continence Problems
Over Sedation
 Delirium
Significant morbidity and mortality
Increased length of hospital stay
Complications and disability
 Dementia
Write short notes on the diagnosis of
dementia syndrome.
Discuss the common causes of
dementia
List the differences between delirium
and dementia
Discuss the diagnosis and management
of a patient diagnosed with dementia.