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DELIRIUM AND DEMENTIA

DANA BARTLETT, RN, 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 as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely about toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center.

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 that is drug induced or due to drug withdrawal. Other relevant neurological problems include mild cognitive impairment and pseudodementia. Most recently, the incidence of missed diagnoses of delirium and dementia have gained attention in the health literature due to health consequences and issues of safety when early recognition and treatment is delayed. The benefits of routine screening of cognitive impairment in a patient with delirium and dementia is of ongoing debate, however there are recognized, useful screening tools that support clinical recognition and proper treatment. General information on dementia and delirium, including risk factors, treatments, and interdisciplinary health team considerations to support patients and their families are raised.

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Policy 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. Continuing Education Credit Designation This educational activity is credited for 4.5 hours at completion of the activity. Pharmacology content is 0.5 hours (30 minutes). Statement of Learning Need Delirium is considered a medical emergency and can have multiple etiologies complicating early recognition. Likewise, the diagnosis of dementia is often delayed or missed in the elderly due to pre-existing conditions that can obscure recognition of early cognitive changes when they occur. Health clinicians in all practice settings need to be able to identify individuals with delirium and dementia by understanding the diagnostic criteria of each disorder, including disease etiology, signs and symptoms, through the use of clinical assessment tools supporting early diagnosis and treatment. Course Purpose To provide health professionals with the information they need to assess, diagnose and treat patients who have dementia or delirium. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members. Disclosures Dana Bartlett, RN, BSN, MSN, MA, CSPI, Jennifer McAnally, DNP, Kellie Wilson, PharmD, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support.

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Self-Assessment of Knowledge Pre-Test: 1. The distinguishing aspect of dementia is

a. inability to perform activities of daily living. b. severe agitation. c. reversible cognitive impairment. d. occurrence before age 50.

2. The most common cause of dementia is

a. vascular pathologies. b. cerebral hemorrhage. c. Alzheimer’s disease. d. Parkinson’s disease.

3. Defining characteristics of delirium include

a. progressive cognitive decline. b. disturbances in cognition and confusion. c. attention deficit disorder. d. acute awareness and attention.

4. The onset of dementia 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.

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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. As clinical diagnoses, dementia and delirium can be confirmed through investigation into etiology, laboratory testing, specific physical findings, or imaging. The relationship between the two diseases is complex. Similarities exist between their presentations; 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. 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 United States becomes older the incidence of these pathologies of aging will certainly increase.

Overview of Delirium and Dementia

The 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.1 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 always necessarily an inevitable consequence of getting old. Statistics

Dementia and delirium are common. The incidence and prevalence rates of dementia and delirium are reflected in the following prevalence rates:2-4

● Delirium is noted in nearly 30% of older people who are hospitalized. ● Postoperative delirium is seen is approximately 10%-50% of general

surgery patients, depending on the health of the patient. ● Community-based studies have found a prevalence of dementia as high as

47% in those 85 years of age and older.

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● Alzheimer’s disease is the most common cause of dementia and approximately 5.5 million Americans currently suffer from Alzheimer’s disease.

● There are many causes of dementia but Alzheimer’s disease accounts for approximately 60%-80% of all cases.

Dementia: Definition, Diagnostic Criteria and Etiology

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

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.1 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 The specific symptoms for major cognitive disorder and mild cognitive disorder are identified as follows: Major Cognitive Disorder 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

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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 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

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● 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; they progress slowly 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 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 Parkinson’s disease

Pick disease Postencephalitic dementia

Progressive multifocal leukoencephalopathy Progressive supranuclear palsy

Trauma Vascular dementia

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The reversible dementias are much less common than the irreversible dementias. Irreversible dementia 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 erythematosus 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.

TABLE 3: DRUGS THAT INDUCE SYMPTOMS OF DEMENTIA/DELIRIUM1

Alcohol Analgesics

Anti-arrhythmics Anticholinergic agents

Anticonvulsants Antidepressants

Antihypertensives Anti-psychotics

Anxiolytics Digoxin

H2 receptor antagonists Non-steroidal anti-inflammatories

Sedative-hypnotics Skeletal muscle relaxers

Steroids

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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.1-6

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.1-6

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 conditions may not be familiar to many nurses and a brief description of each one is provided below.1-6

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.5,6 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.5,6

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.5,6

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Frontotemporal Lobe Dementia

Frontotemporal lobe dementia is a neurodegenerative disease caused by atrophy of the frontal and temporal lobe.7 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 a chronic, progressive, and there is no cure.7 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.3,5 The cause of Lewy body dementia is not known. It is clinically distinguished from other types of dementia with Lewy bodies and by varying levels of alertness and attention, especially reduced responsiveness, visual hallucinations, and Parkinsonian motor signs, such as tremors, stiffness, and walking/ balance problems.3,5

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.3,5 Parkinson’s Disease

Parkinson’s disease is caused by chronic and progressive destruction of dopamine-producing cells in the substantia nigra area of the brain.8 Parkinson’s disease often causes dementia but it is distinguished by

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characteristic motor symptoms such as bradykinesia (slowness of movement), gait disturbances, rigidity, and tremor.8

The mean prevalence of dementia reported in cross-sectional studies of Parkinson’s disease is estimated as 30 to 40 percent.8 Prospective cohort studies suggest that the incidence of dementia in patients diagnosed with Parkinson’s disease is an approximate 100 per 1000 patient-years; this is a rate approaching 5 to 6 times higher than those studied without Parkinson’s disease.8 The occurrence of dementia inpatients with Parkinson’s disease appears inevitable based on the existing research. More than 80 percent of people reported > 20 years after onset of PD will be diagnosed with dementia at varying degrees.8 Milder degrees of cognitive impairment are common during the earlier phase of Parkinson's disease diagnosis with mild cognitive impairment reported in approximately 10 to 35 percent of new Parkinson’s disease cases.8

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.9 There is no cure for Parkinson’s disease but there is effective symptomatic treatment, and the progression of the disease can be delayed.8,9 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), and various types of lesions like lacunar lesions.3 There are many causes of vascular dementia, and atherosclerosis, diabetes, hypercholesterolemia, hypertension, and smoking are significant risk factors for the development of this pathology.3

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Delirium: Definition, Diagnostic Criteria and Etiology

Delirium is an acute change in mental status characterized by confusion and disturbances in cognition.3,6 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 outlined below.

Delirium: DSM-5 Diagnostic Criteria6

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 comma.

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 at high risk of a substance use disorder or 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.11

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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. This also includes individuals whose activity level rapidly fluctuates.11

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.

Medications should be reviewed as a potential cause of delirium,

although no specific medication is known to cause delirium. Generally, it is the cumulative effect of a medication, such as anticholinergic properties, that leads to a state of delirium.11 Various scales or charts can be used to determine delirium that is drug induced. Examples include the Anticholinergic Burden Classification (ABC), Anticholinergic Drug Scale (ADS), Anticholinergic

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Risk Scale (ARS), Anticholinergic Cognitive Burden Scale (ACB), Clinician-rated Anticholinergic Score, Anticholinergic Activity Scale (AAS) and Anticholinergic Loading Scale (ACL).11 The ABC is the most commonly used tool and includes a list of medications and their anticholinergic propensities. Clinicians should be aware of the appropriate antidote of a drug-induced delirium, toxicity or intoxication. Alcohol-induced delirium is typically treated with benzodiazepines, and high doses of thiamine.11

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, fractures, 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.1,11 More could be said about the effects of nutritional deficiencies in the elderly and the need for vitamin supplementation.11

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

depression, another psychiatric disorder, or attributed to old age.10,11 This under recognition can delay treatment, and it can also prolong the duration of delirium and expose the patient to permanent neurological damage.

The common causes of delirium are important to identify and for the

education of family and home caregivers. Family members encounter significant distress when witnessing the clinical manifestation of delirium, so addressing the family members understanding of common causes and the nature of the syndrome is important to disease management and their role as family members.11

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TABLE 4: COMMON CAUSES OF DELIRIUM1

Acute blood loss Acute myocardial infarction

Acute psychosis 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 Parkinson’s disease

Stroke (small cortical) Urinary retention Visual impairment

Mild Cognitive Impairment and Pseudodementia

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.12

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.12 There are differences in the diagnostic criteria for MCI and these criteria are not precise, but MCI is generally

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considered to be an intermediate state between normal cognitive functioning and dementia. In their 2014 review, Langa, et al. used the following criteria for the diagnosis of MCI:12 ● 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.12,13 The patient who has MCI is aware of the change in memory, unlike the person who has dementia. Mild cognitive impairment may be temporary and a reversion to normal mental status is possible but approximately 5%-20% of people who have MCI will develop dementia.13,14

Pseudodementia 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 symptoms, so a misdiagnosis is relatively common. Some key differences between dementia and depression are listed next:14-16 ● Depression has a relatively abrupt onset but the onset of dementia is slow. ● Dementia progresses while depression plateaus.

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● 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 misdiagnosed.4

The incidence of a missed diagnosis of dementia has been reported to

be as high, depending on the severity of the case and who is doing the assessment. Eight studies were systematically reviewed that considered the underdiagnosis of dementia amongst primary care providers with variable results. For example, the underdiagnosis of Alzheimer’s disease in studies varied from 4% to 75%, and in Lewy body dementia the differences in missed diagnosis ranged between 71% to 100%.17 Factors affecting timely identification of dementia included “poor access to health care, lower socioeconomic status, and lower levels of education were more likely to be underdiagnosed.”17

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.

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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.18,19 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.18-20 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. 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.21 The interviewer should ask specific questions about the patient’s day-to-day life, for example, 1) Has the patient been agitated, disruptive, or verbally aggressive? 2) Has there been wandering behavior or dangerous driving? 3) Has the patient had difficulty sleeping? 4) 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 with regard to the following deficits or behaviors: 1) Problems with judgment, 2) Reduced interest in activities or

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hobbies, 3) Repeating questions, stories, or statements, 4) Trouble learning how to use an appliance or tool, 5) Forgetting what month or year it is, 6) Unable to handle simple financial affairs, 7) Forgetting appointments, and 8) Consistent problems with memory and/or thinking.21

Medical and Surgical History

The patient’s medical and surgical history should be carefully reviewed.20 This review should include the medical history of the patient’s immediate family, i.e., parents and siblings. Asking about alcohol or drug use can be uncomfortable but it should be done; and, it is often helpful to obtain collateral report of the patient’s history of alcohol or drug use. Varied etiologies of abnormal performance can occur in a wide range of medical conditions that affect the brain.20

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 medications as prescribed. There may have been inadvertent or intentional overdose, the patient may have been skipping doses, or have simply stopped taking a prescribed medication.21 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.1-3 For example, bradykinesia and gait disturbances are characteristic of Parkinson’s disease, the presence of papilledema suggests that the patient may have a

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brain tumor or a subdural hematoma, and myoclonus can indicate the presence of human immunodeficiency virus (HIV)-related dementia.1-3 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. 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.23,24 The 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.24,25

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.25-27 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. 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

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clinician is examining or interviewing the patient, it is important to pay special attention to the following symptoms:1-4 ● 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 the following

conditions:1-4 ● 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.1,4 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

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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 and can be useful in differentiating dementia from depression.1,4

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.28-30 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).29 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 section but several will be reviewed here. In-depth information on dementia screening tests are available in the current literature. 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.3,4 The test is not considered to be sensitive for mild dementia and performance may be affected by age and level of education.4 The Mini-Mental Status Exam 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 the patient learns all three. Count and record the number of trials. The first

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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 the 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 to write a sentence. Sentences 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.3,4 Mini-Cog

The Mini-Cog test requires the patient to: 1) Draw a clock with the numbers in the correct sequence and the clock hands correctly indicating the current time; and, 2) Perform an uncued recall of three objects.33

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, the patient is asked to tell the interviewer the names of the three objects. Each correctly

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recalled word is worth one point and the clock is considered normal if the time is correct and the clock is grossly normal.33

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.33 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.33 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.34

When using the CDR, the patient’s abilities are assessed in the areas of

community affairs, home and hobbies, judgment, memory, orientation, and problem solving. The patient is evaluated in these areas on his/her abilities and performances as follows:34

● 0 = None ● 0.5 = Very mild ● 1 = Mild ● 2 = Moderate ● 3 = Severe

The ratings and interpretations are categorized as follows:34

● 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

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Montreal Cognitive Assessment (MOCA)

The Montreal Cognitive Assessment has been shown to be a useful screening tool for detecting mild cognitive impairment, notably in patients who have Alzheimer’s disease, and for identifying people with cognitive impairment who are at risk for developing dementia and who have been diagnosed with dementia.35,36 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, but additional information can be found online at the mocatest.org website.35,36

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.1,37-39 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.1

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,

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changes in social circumstances, daily activities, elimination patterns, food and fluid intake, and mood.1 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

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.1 Similar to the history taking with dementia, the history should include a thorough investigation into the patient’s use of substances. Since the patient may not be forthcoming or unable to inform the interviewer about the history of substance use, it may be necessary to ask someone other than the patient about the patient’s use of alcohol and/or illicit drugs. Medication

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.1 It is important to determine if the patient has been taking medications as prescribed. There may have been inadvertent or intentional overdose, the patient may have been skipping doses, or 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.1

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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.38,39 For example, a 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.1

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 ● Executive functioning, i.e., planning, weighing alternatives ● General appearance and behavior ● Insight and judgment ● Memory, short-term and long-term ● Language ● Level of consciousness

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● 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 may include cognitive, mood and thought disordered symptoms:1 ● 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).3 The CAM has been shown to be accurate and reliable.3 It is easy to administer

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and it can be used in a wide variety of clinical situations but it does require considerable training to use correctly. The CAM compares well to other delirium screening tests, but it should be remembered that no screening test is perfect for detecting delirium.3

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 in Table 5; the diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.3,40

TABLE 5: 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 the patient 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.

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Clinical Care of Dementia

Clinical care and treatment of the patient who has dementia should focus on communication neuropsychiatric behavioral issues, safety and comfort, pain control, and 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.41 Hearing and speech impairments may be present and depression may negatively influence the patient’s desire to communicate.

Limitations of the patient with dementia does 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.41

Health team members caring for the dementia patient need to assess

the patient’s communication abilities and needs and then adjust to the patient’s communication style.41 If the clinician in attendance can do this, the interactions between the clinician and patient will be effective and satisfying. This is done on an individual basis but there are some simple principles all health team members should keep in mind when communicating with a patient who has dementia. Self-identity

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.41,42 When a member of the health team acknowledges a patient’s self-identity, the patient’s disruptive and combative

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behavior is often dissipated. The challenge for health team members is to discover the patient’s self-identity.42

Personalized Communication

Home-based caregivers and family members often develop effective personalized communication patterns with patients and it can be very helpful for health team members to ask them how they communicate with the patient.41

Reality Orientation

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.43

Potential scenarios would be that a health team member approaches a patient by introducing himself or herself each time he or she talks to the patient. Other methods of reality orientation could involve the use of calendars and clocks during conversation and talking with the patient about current events and the plans for the day.

Clear Speech

Speaking clearly and slowly is important in the facilitation of meaningful and successful conversation with the patient who has dementia. Remembering to make eye contact and using short sentences promotes clarity of communication.41 Waiting for responses and not answering for the patient is another helpful strategy. The health team member approaching the dementia patient should avoid finishing sentences or interrupting the patient during conversation.

Minimize Distractions

If the patient cannot answer or respond correctly at first, the clinician should try again. Being aware of one’s tone and volume of voice and body

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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.41

The Alzheimer’s Association publishes a guideline on communicating with patients who have dementia that outlines some of these strategies (alzheimers.org). Neuropsychiatric Behavioral Problems

Neuropsychiatric behavior problems are a common and serious complication of dementia. 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.44 They are also potentially dangerous and if not properly managed, they can increase the incidence of morbidity and mortality and increase the 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.44

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.44 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

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pharmacological intervention.44 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, and the patient is very aggressive and may harm self 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.45 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:

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● 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 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.

Maintaining Patient Safety and Comfort

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.

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Discomfort is a common source of behavioral problems for the patient who has dementia. The patient 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.46,47 Pain Control

Pain is very common in patients who have dementia, and it is often under-recognized and under treated.48-50 Patients who have dementia do not experience any less pain than older adults without dementia, but assessment of 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.48-50 Untreated pain can cause behavioral problems and psychological distress, 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. However, for the patient who has dementia this is often not an option. Members of the health team will need to use professional judgment and an assessment tool to determine the patient’s level of pain.

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 it has high-to-excellent reliability and validity.48,50-52 The MOBID-2 is very reliable for detecting the presence of pain in patients who have dementia

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and could also be used to assess the response to pain treatments.52 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.52

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 no controlled studies existed on the use of codeine, non-steroidal anti-inflammatories, or tramadol.50

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 cholinesterase inhibitors and memantine.53-55

The drugs most commonly used to treat dementia are the cholinesterase

inhibitors.53-55 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.53-55 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.53-55

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.53-55 The long-term benefits of the

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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.53-55 Regardless, most sources recommend a trial period of cholinesterase inhibitors and donepezil, galantamine, or rivastigmine can be used; they appear to be equally effective.53-55 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.53-55

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.53-55

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.53-55 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.56

The use of antipsychotics for treating behavioral problems associated

with dementia is somewhat controversial. Brasure, et al., in their 2016 review, wrote 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.”46 Greenblatt, et al. (2016), however, note that the conventional and atypical antipsychotics “... appear to have modest to moderate clinical efficacy in the treatment of these symptoms.”57 Both of these authors acknowledge the increased risk of mortality associated with the use of antipsychotics in this

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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”.57 However, Greenblatt, et al., do caution that the dose and duration of therapy of these drugs should be minimized and that patients should be continuously monitored for adverse effects.57

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.23 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. There is limited evidence for their benefit and the adverse effects and risks of their use are considerable.58

Depression is best treated with a selective serotonin reuptake

inhibitor.59 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.59,60

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, ginkgo biloba, lamotrigine, melatonin, methylphenidate non-steroidal anti-inflammatories, selegiline, statins, trazodone, valproate, vitamin B6, vitamin B12, and vitamin E.59,60 At this time, there is either no evidence or very limited evidence that any of these drugs, supplements, or vitamins are effective. 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.61

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Delirium: A Medical Emergency

Delirium is a medical emergency. Therapies and interventions that would be appropriate when treating most patients who have delirium including attending to hydration needs, assessing the level of stimulation (under- and over-stimulation), sleep patterns, pain levels, reorientation techniques and possibly a bedside sitter. Attending to the sensory needs of the patient is important, such as making sure the patient has corrective lenses and/or hearing aid if needed. If possible, close contact with a family member or someone familiar to the patient is encouraged.62,63

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

for patients who have delirium. Physical restraints should not be used unless other interventions have failed and there is a risk to the patient or others.62,63 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.

The standard pharmacological therapy for treating patients who have delirium and who do not respond to non-pharmacological interventions is haloperidol. Haloperidol and the atypical antipsychotics olanzapine, quetiapine, risperidone ziprasidone have all been shown to be effective in treating delirium. 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, but in other types of delirium they may worsen the patient’s confusion and cause sedation.62,63

Case Study: Delirium in a Hospitalized Patient

The authors of this case study reported on a 68-year-old woman of

European descent who had been hospitalized and required an interpreter. The patient had been diagnosed with uterine cancer and had been admitted to the oncology unit of the hospital.64 A psychosocial history was completed by the hospital social worker that indicated the patient lived alone but had family and

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social support. She maintained independent activities of daily living and kept involved socially.

In the first 48 hours of admission the patient was observed to suffer

from insomnia, showed signs of being restless, emotionally labile and tearful, and physically tremulous. She developed gastrointestinal symptoms with onset of diarrhea and was at risk of dehydration. Nurses observed she would talk loudly in her language of origin while alone in her room and thought she may be hallucinatory and responding to internal stimuli. They intervened by assisting her to distract and redirect from the thought of someone being in the room with her while she was actually alone. Translation services were contacted and it was determined that the patient was both confused and disoriented. Non-pharmacological interventions used to alleviate her confused and anxious state were ineffective and the patient continued to talk loudly and showed increased mood and thought dysregulation.

The interdisciplinary health team convened and consulted with a

geriatric advanced practice nurse who met with the patient and provided a report of assessment. The patient’s vital signs showed a temperature 98.6, pulse 102, and blood pressure 112/68 mmHg. Auscultation of the patient’s lungs revealed bilateral clear sounds and the oxygen saturation was 96% on room air. The patient’s general skin condition showed poor turgor, and the patient’s abdomen appeared soft and nontender with hyperactive bowel sounds in all four quadrants.

As the patient’s restless and agitated state progressed, she escalated

with loud crying and rocking her body back and forth. She became increasingly incoherent, nonsensical on her responses to the appointed interpreter, and was unable to answer questions or cooperate with basic redirection. She was unable to participate in a Mini-Mental State Examination (MMSE) therefore the Confusion Assessment Method (CAM) was administered and was positive.

The patient’s daughter also provided collateral report that the patient’s

behavior of crying out, confusion and restlessness was markedly different from her usual behavior. She was diagnosed with delirium secondary to suspected

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pain. Before the onset of delirium, the patient’s pain assessment was negative. Using an observational pain scale, the patient was assessed as having pain and her daughter was reached for reconciliation of her home medications. Her daughter reported use of Fentanyl patch to treat uterine cancer pain. The patient had not been administered Fentanyl patch during the course of her hospital stay, and it was determined she was undergoing Fentanyl withdrawal symptoms. The treatment for Fentanyl withdrawal was the administration of intravenous (IV) Morphine in addition to the application of a transdermal Fentanyl patch and the patient’s pain symptoms resolved.

Discussion

The authors reported that the patient’s delirium was due to narcotic

withdrawal resulting from an unintended discontinuation of pain medication for the treatment of uterine cancer.64 This was the result of missing the routine use of Fentanyl for pain management at home during the admission reconciliation of home medications.64

Mention was made that pain in older adults often goes under-treated

and tends to be a common cause of delirium. Assessment tools exist to support a clinical determination of pain in older adults when they are unable to communicate. Older adults diagnosed with cognitive impairment and/or unable to communicate pose a barrier to identifying when pain is a problem. In the case of this patient with a diagnosis of uterine cancer, she also had a language barrier and could not describe her pain. Often, older adults with delirium or dementia are unable to verbalize pain, so appropriate selection of a pain assessment tool should accommodate the patient’s unique situation.64

The authors reported that an approximate 50 percent of older adults in

a community setting and 85 percent of older adults residing in nursing homes experience chronic pain. Chronic pain in older adults, especially when cancer has been diagnosed, is typically treated with narcotics. They recommended that pain assessment initially start with a self-report and be followed with a pain assessment tool to determine the location, type, and level of pain. A comprehensive physical assessment and patient history should be done to

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determine the pathophysiology and cause of pain. Polypharmacy in older adults is often suspected as a common cause of delirium but another possible cause can be withdrawal from prescribed pain medication for chronic pain. In this patient’s case, her daughter helped to determine the cause of the patient’s delirium, which was acute withdrawal.64

Summary

Dementia and delirium are neurological disorders that cause significant 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. The incidences of dementia and delirium are likely to increase as the population of elderly continue to rise. Treatment of dementia and delirium is primarily symptomatic and supportive unless there is a clearly identified etiology. Clinical care of the patient diagnosed with either dementia or delirium include vital sign monitoring, behavioral and environmental interventions, safety and comfort, pain control, and safe administration of medications.

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Course Test 1. The distinguishing aspect of dementia is

a. an inability to perform activities of daily living. b. severe agitation. c. reversible cognitive impairment. d. that it usually arises before age 50.

2. The most common cause of dementia is

a. vascular pathologies. b. cerebral hemorrhage. c. Alzheimer’s disease. d. Parkinson’s disease.

3. Defining characteristics of delirium include

a. progressive cognitive decline. b. disturbances in cognition and confusion. c. attention deficit disorder. d. acute awareness and attention.

4. The onset of dementia 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.

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

a. True b. False

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7. A key difference between dementia and depression is

a. dementia has an abrupt onset. b. dementia progresses while depression plateaus. c. patients with depression have variable emotions whereas dementia

patients do not. d. dementia fluctuates and has regressive characteristics.

8. Physical restraints should NOT be used with patients who have

dementia unless

a. the patient is agitated or confused. b. there is a significant risk for a fall. c. all other interventions fail and there is a serious risk of harm. d. the patient tends to wander.

9. Neuropsychiatric behavior problems in patients who have

dementia

a. are often caused by internal and/or external stimuli. 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. galantamine. d. bupropion.

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12. True or False: Use of cholinesterase inhibitors is the first-choice therapy for treating patients who have delirium.

a. True b. False

13. Using benzodiazepines to treat dementia is

a. the first-line treatment option. b. absolutely contraindicated. c. seldom useful and the adverse effects and risks are considerable. 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. Alcohol-induced delirium is typically treated with

benzodiazepines, and high doses of

a. thiamine. b. memantine. c. vitamin C. 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. progress slowly.

17. The Diagnostic and Statistical Manual of Mental Disorders, fifth

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

a. major or mild cognitive disorder. b. progressive cognitive disorder. c. neurocognitive spectrum disorder. d. progressive cognitive syndrome.

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18. With major and mild cognitive disorder, cognitive defects

a. are not variable. b. do not occur exclusively in the context of a delirium. c. are explained by a concomitant mental disorder. d. interfere with the person’s capacity to perform everyday activities

independently. 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 may cause irreversible dementia?

a. Carbon monoxide poisoning b. Dementia associated with Lewy bodies c. Infections d. All of the above

22. In most cases, dementia caused by _______________ is

reversible.

a. carbon monoxide poisoning b. dementia associated with Lewy bodies c. a drug d. arteritis

23. Drugs that can cause dementia or delirium include

a. alcohol. b. anti-arrhythmics. c. skeletal muscle relaxers. d. All of the above

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

a. lesions b. protein deposits c. dopamine-producing cell destruction d. thrombotic obstructions

25. Frontotemporal lobe dementia is a neurodegenerative disease

caused by _____________ of/in the frontal and temporal lobe.

a. thrombotic obstructions b. atrophy c. protein deposits 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

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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.

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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. ______________________ is a 10-minute test that has been

shown to be a useful screening tool for detecting mild cognitive impairment (MCI) in patients who have Alzheimer’s disease.

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.

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39. Mild cognitive impairment is a term used to describe cognitive deficits that are in an intermediate state

a. of being conscious and unconscious. b. delirium and dementia. c. 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

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44. The Confusion Assessment Method (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), an initial 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 health team member should avoid finishing sentences for the patient or interrupting the patient.

a. True b. False

47. When a health team member 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. An example of ____________ would be a health team member

introducing himself or herself to a patient each time he or she talks to the patient.

a. acknowledging the patient’s self-identity. b. recognizing limitations. c. an inability to communicate. d. reality orientation.

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49. Successful conversation with a 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 health team member 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.

a. DICE Method b. Confusion Assessment Method (CAM) c. Montreal Cognitive Assessment (MOCA) d. Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2).

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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 with cholinesterase inhibitors, the dose

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 dosing 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. d. None of the above

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

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

a. confusion. b. delirium. c. characteristic motor symptoms. d. All of the above

60. The characteristic motor symptoms of Parkinson’s disease

include

a. numbness and tingling. b. bradykinesia (slowness of movement). c. sarcopenia. d. a sudden onset of temporary limb weakness.

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