lec 4 delirium dementia
DESCRIPTION
deliriumTRANSCRIPT
DELIRIUM & DEMENTIA
1
Confusion in the Elderly
Confusion is usually a symptom of delirium or dementia patient may have both
RAC
GP
Med
ical
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old
er p
erso
ns in
res
iden
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ged
care
fac
ilitie
s (4
th e
ditio
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2
Delirium or Dementia?Analogy courtesy of Stefan Kowalski
DementiaDelirium
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Assessing Cognitive Function
Useful to assess and document
severity of cognitive impairment
measure changes in cognitive function over time
4
Delirium
An acute or subacute deterioration in mental functioning that occurs commonly in the older population cause is usually multifactorial and reversible
RAC
GP
Med
ical
car
e of
old
er p
erso
ns in
res
iden
tial a
ged
care
fac
ilitie
s (4
th e
ditio
n)
plus
or
and
5
DeliriumPrecipitating Factors
RAC
GP
Med
ical
car
e of
old
er p
erso
ns in
res
iden
tial a
ged
care
fac
ilitie
s (4
th e
ditio
n)
Anticholinergic drugsDiuretics
6
DeliriumPrecipitating Factors
RAC
GP
Med
ical
car
e of
old
er p
erso
ns in
res
iden
tial a
ged
care
fac
ilitie
s (4
th e
ditio
n)
possibly drug induced
Anticholinergic drugsDiuretics
7
DeliriumPrecipitating Factors
8
http
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DeliriumPrecipitating Factors
9
http
://w
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Managing Delirium
NICE clinical guideline 103: Delirium Diagnosis, prevention and management (2010)
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Delirium ManagementTreat Precipitating Factors
RAC
GP
Med
ical
car
e of
old
er p
erso
ns in
res
iden
tial a
ged
care
fac
ilitie
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ditio
n)
As per Theory 1
Review need for potential contributing
medications
Diuretics
Anticholinergic drugsDiuretics
11
Delirium Precipitating FactorsAnticholinergic Drugs
12
Delirium ManagementAcute Management of Delusions and Hallucinations
Ther
apeu
tic G
uide
lines
: Psy
chot
ropi
c,ve
rsio
n 6
13
Acute Management of Delusions and Hallucinations
Risks
Risks to be discussed in
schizophrenia
Ther
apeu
tic G
uide
lines
: Psy
chot
ropi
c,ve
rsio
n 6
14
Assessment and Management of Delirium
N E
nglJ
Med
200
6;35
4:11
57-6
5
Acute or Chronic
Identify and treat underlying
cause
Short term management of agitation if necessary
15
Dementia
Onset ≥ 65yo
Onset < 65yo
ALZHEIMER'S AUSTRALIA (2005) DEMENTIA ESTIMATES AND PROJECTIONS: AUSTRALIAN STATES AND TERRITORIES
Pract Neurol 2009;9:241-251
16
Dementia
Pract Neurol 2009;9:241-251
17
Alzheimer’s Disease Natural History
Alzheimer’s disease: symptomatic drugs under development. In: Gauthier S, ed. Clinical Diagnosis and Management of Alzheimer’s Disease. Boston, MA: Butterworth-Heinemann; 1996:239-259.
18
Alzheimer’s Disease Natural History
Euro
pean
Jou
rnal
of
Neu
rolo
gy 1
998.
Vol
S (s
uppl
4)
19
Alzheimer’s DiseaseAdditional Cognitive Assessment Tools
Alzheimer’s disease: symptomatic drugs under development. In: Gauthier S, ed. Clinical Diagnosis and Management of Alzheimer’s Disease. Boston, MA: Butterworth-Heinemann; 1996:239-259.
ADAS‐CogAlzheimer’s Dementia Assessment Scale ‐ CognitiveA more extensive assessment tool developed specifically for Alzheimer’s DiseaseScore‐: 0‐70 (higher scores worse)Improvement ≥4 considered clinically significant
CIBIC (±carer)Clinician's Interview-Based Impression of Change
Subjective overview of general patient functioning, cognition, behaviour and activities of daily livingScore: 1‐7 (very much improved ‐ very much worse)
Limitations other than Alzheimer’s to completing MMSE
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Management of Dementia
Prevent progression not possible for Alzheimer's Disease
Improve cognitive function Manage behavioural disturbances Reduce carer burden
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Management of Vascular (Multi-infarct) Dementia
Pract Neurol 2009;9:241-251
Address stroke risk factors
22
Management of Alzheimer’s Disease
Ther
apeu
tic G
uide
lines
: Psy
chot
ropi
c,ve
rsio
n 6
23
Don
epez
ilRi
vast
igm
ine
Gal
anta
min
e
Cholinesterase InhibitorsBenefit: Cognitive Improvement
Ann
als
of G
ener
al H
ospi
tal P
sych
iatr
y 20
03, 2
:1
24
Cholinesterase InhibitorsBenefits: Improvement in MMSE
The
Coc
hran
e Li
brar
y 20
12, I
ssue
5
25
Benefit: Improvement in MMSEDonepezil v Rivastigmine
The
Coc
hran
e Li
brar
y 20
12, I
ssue
5
26
Alzheimer’s DiseaseAChEI do not treat underlying cause
N E
nglJ
Med
200
4;35
1:56
-67
27
Cholinesterase InhibitorsBenefits: Improvement in MMSE
Am
J P
sych
iatr
y 20
07;1
64:8
49-8
52.
28
Cholinesterase InhibitorsOld PBS Restriction: Initial Supply
29
Cholinesterase InhibitorsOld PBS Restriction: Initial Supply
30
Cholinesterase InhibitorsOld PBS Restriction: Continuing Tx
31
Review of PBS Anti-dementia Drugs32
33
Cholinesterase InhibitorsCurrent PBS Restriction: Continuing Tx
Review of PBS Anti-dementia Drugs34
Review of PBS Anti-dementia Drugs35
Cholinesterase InhibitorsBenefits: Activities of Daily Living
The
Coc
hran
e Li
brar
y 20
12, I
ssue
5
36
Cholinesterase InhibitorsBenefits: Behavioural Disturbance
The
Coc
hran
e Li
brar
y 20
12, I
ssue
5
37
Cholinesterase InhibitorsBenefits: Carer Input
The
Coc
hran
e Li
brar
y 20
12, I
ssue
5
38
Benefits: Behavioural DisturbanceDonepezil v Rivastigmine
The
Coc
hran
e Li
brar
y 20
12, I
ssue
5
39
40
Cholinesterase InhibitorsCurrent PBS Restriction: Continuing Tx
Review of PBS Anti-dementia Drugs41
Cholinesterase InhibitorsRisks
42
Cholinesterase InhibitorsRisks: Withdrawal due to adverse effect
The
Coc
hran
e Li
brar
y 20
12, I
ssue
5
43
Risks: Withdrawal due to adverse effectDonepezil v Rivastigmine (oral)
Nausea Vomiting
Anorexia Diarrhoea
The Cochrane Library 2012, Issue 5
44
Cholinesterase InhibitorsManaging Risks
Start low and uptitrate after 4 weeksRivastigmine patch
45
Management of Alzheimer’s Disease
Therapeutic Guidelines: Psychotropic, version 6
46
MemantineBenefits: ADAS-Cog
Mild
(MM
SE 2
0-23
)M
oder
ate
(MM
SE 1
0-19
)
Arch Neurol. 2011;68(8):991-998
47
MemantinePBS Restriction: Initial Supply
48
MemantineRisks
49
Donepezil plus Memantine
JAMA. 2004 Jan 21;291(3):317-24
Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus) scale
50
Management of Behavioural Disturbances
Therapeutic Guidelines: Psychotropic, version 6
51
Management of Behavioural DisturbancesRisks
Risks to be discussed in schizophrenia and Parkinson’s disease
Risks to be discussed in anxiety
Therapeutic Guidelines: Psychotropic, version 6
52
Management of Behavioural DisturbancesRisks
Pract Neurol 2009;9:241-251
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Management of Behavioural DisturbancesRisks – Cerebrovascular Adverse Events
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Management of Behavioural DisturbancesRisks – Cerebrovascular Adverse Events
CNS Drugs 2005; 19 (2): 91-103
Serious CVAE: defined as death, life-threatening, requiring hospitalisation or leading to persistent disability
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Management of Behavioural DisturbancesRisks – Managing Cerebrovascular Adverse Events
CNS Drugs 2005; 19 (2): 91-103Serious CVAE: defined as death, life-threatening, requiring hospitalisation or leading to persistent disability
Non-drug techniquesUse lowest dose required
Limit duration of treatment (<12 weeks)
Minimise drug exposure
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Management of Behavioural DisturbancesFactors that contribute to behavioural disturbances
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Non-drug techniques for behavioural disturbances
Education explanation for residents and relatives/carers, training of RACF staff
Sensory stimulation orientation cues, diversional activities, music, massage, pets
Cognitive reminders and repetition of information
Self care skills dressing, eating, toileting
Physical activity simple exercise routines
walking, gentle exercise groups
Social interaction regular social activity, groups, and visitors
Behavioural therapies re-orientation, reminiscence
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