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DELIRIUM AND

DEMENTIA

DANA BARTLETT, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center

information specialist. Dana has published numerous CE and journal articles, written NCLEX material and textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students.

ABSTRACT

There are many possible causes of dementia and delirium. The more common causes are complex, such as dementia of the Alzheimer’s type or delirium due to drug withdrawal. Other relevant neurological problems include mild cognitive impairment and pseudo-dementia. While detailed and extensive information about the specific causes of these diseases is outside the scope of this study, general information on dementia and delirium, including risk factors, treatments, and nursing considerations are discussed. Accreditation Statement

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This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.

Credit DesignationThis educational activity is credited for 4.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 0.5 hours (30 minutes).

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.

Statement of Learning Need

Nurses in all practice settings that care for individuals with dementia and delirium need to understand what defines each disorder, and diagnostic criteria related to etiology, clinical assessment and signs and symptoms.

Course Purpose

To provide professional nurses with the information they need to


assess and care for patients who have dementia or delirium.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Director Disclosures

Dana Bartlett, RN, BSN, MA, MSN, CSPI, William S. Cook, PhD, Douglas Lawrence, MS, Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures.

Acknowledgement of Commercial Support

There is none.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

1. One of the defining characteristics of dementia is a. inability to perform activities of daily living.b. severe agitation.


c. reversible cognitive impairment. d. occurrence before age 50.

2. Most cases of dementia are caused by

a. trauma and heavy metal poisoning.b. infections and hemorrhage.c. Alzheimer’s disease and vascular pathologies.d. hypoxia and Parkinson’s disease.

3. Defining characteristics of delirium include

a. movement disorders and a progressive cognitive decline.b. attention deficits and confusion. c. expressive aphasia and hypotension.d. hyperthermia and depression.

4. The onset of delirium is

a. acute.b. slow.c. chronic.d. fluctuating.

5. Common causes of delirium include

a. Parkinson’s disease and advanced age.b. drug withdrawal and Lewy body dementia.c. acute blood loss and frontotemporal dementia.d. drugs and dementia.

Introduction

Dementia and delirium are the major causes of cognitive impairment in the elderly, and they are syndromes caused by a wide range of medical, neurological and psychiatric pathologies.1 As clinical


diagnoses, dementia and delirium can be confirmed through investigation into etiology, laboratory testing, specific physical findings, or imaging. In addition, the relationship between the two diseases is complex. There are similarities in their presentation; dementia is a major risk factor for delirium, and delirium occurs in many patients who have dementia. Dementia and delirium can be acute or subacute, and they can be transient and reversible or they can cause permanent impairment. Both dementia and delirium are associated with increased morbidity and mortality, and their risk increases with advancing age. As the population in the U.S. becomes older the incidence of these pathologies of aging will certainly increase.

Overview Of Delirium And Dementia

Slowing of cognitive function can occur with aging and it is not uncommon for older people to have mild memory deficits or a decreased speed with which information is processed. Old age is a major risk factor for dementia, but advanced age itself does not cause a decrease in cognitive and intellectual ability that interferes with daily functioning. In brief, dementia is not an inevitable consequence of getting old.

Statistics

Dementia and delirium are very common. The incidence and prevalence rates of dementia and delirium are reflected in the following prevalence rates.1-5


Delirium is noted in 14%-56% of elderly patients who are hospitalized and in 40% of patients admitted to intensive care.

Postoperative delirium is seen is approximately 5%-10% of general surgery patients.

Community-based studies have found a prevalence of dementia as high as 47% in those 85 years of age and older.

Alzheimer’s disease is the most common cause of dementia and in 2013 there were approximately 5 million Americans who suffered from Alzheimer’s disease.

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

Delirium occurs in approximately 50% of older hospitalized patients and 70% of older long-term care patients.

Dementia: Definition, Diagnostic Criteria And Etiology

Dementia can be defined in several ways. Kane, et al. (2013) defines dementia as “... a clinical syndrome involving a sustained loss of intellectual functions and memory of sufficient severity to cause dysfunction in daily living.”1 This definition emphasizes key points about dementia that are important to remember.

First, the distinguishing aspect of dementia is an inability to successfully perform the activities of daily living, caused by impaired cognitive and intellectual capacity. Second, dementia is a syndrome. A syndrome is a set of signs and symptoms that can have many different causes, and that is especially true with dementia. There is a multitude of etiologies of dementia. And finally, because dementia has no single cause or type of cause the clinical picture of dementia can be variable.


The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) has replaced the term dementia with the terms major cognitive disorder and mild cognitive disorder.6

Major Neurocognitive Disorder: DSM-5 Diagnostic Criteria

1. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex atten-tion, executive function, learning and memory, language, per-ceptual-motor, or social cognition) based on: a) concern of the in-dividual, b) a knowledgeable informant or the clinician finds there has been a significant decline in cognitive function; and, c) a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.

The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or man-aging medications).

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

3. The cognitive deficits are not better explained by another mental disorder (i.e., major depressive disorder, schizophrenia).

Minor Neurocognitive Disorder: DSM-5 Diagnostic Criteria

1. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex atten-


tion, executive function, learning and memory, language, per-ceptual-motor, or social cognition) are based on a) concern of the individual, b) a knowledgeable informant, c) the clinician’s as-sessment 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, an-other quantified clinical assessment.

2. The cognitive deficits do not interfere with capacity for indepen-dence 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 ac-commodation may be required).

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

4. The cognitive deficits are not better explained by another mental disorder (i.e., major depressive disorder, schizophrenia).

When making the diagnosis of major or minor neurocognitive disorder it must be specified if the disorder is due to one of the following:

Alzheimer’s disease Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic brain injury Substance/medication use HIV infection Prion disease


Parkinson’s disease Huntington’s disease Another medical condition Multiple etiologies Unspecified

Dementia can be usefully divided into two categories: reversible and irreversible. Most cases of dementia are irreversible. These dementias slowly progress and the patient’s condition worsens over time.

Degenerative diseases of the nervous system, infections, trauma, and vascular disorders cause irreversible dementias. The most common irreversible dementias are dementia of Alzheimer’s disease, frontotemporal dementia, Lewy body dementia, Parkinson’s disease, and vascular dementia. Many patients who have dementia have a neurodegenerative and a vascular pathology.7

Table 1: Irreversible Causes of Dementia1

Acquired immunodeficiency syndromeAlzheimer disease

Anoxia secondary to cardiac arrest Arteritis

Binswanger disease


Carbon monoxide poisoning Cerebrovascular disease, i.e., multi-infarct dementiaCraniocerebral injury, including dementia pugilistica

Creutzfeldt-Jakob diseaseHuntington’s disease

Dementia associated with Lewy bodiesFrontotemporal dementia

InfectionsParkinson’s disease

Pick diseasePostencephalitic dementia

Progressive multifocal leukoencephalopathyProgressive supranuclear palsy

TraumaVascular dementias

The reversible dementias are much less common than the irreversible dementias. Irreversible dementias can be successfully treated but find-ing and treating the cause does not guarantee a cure.

Table 2: Reversible/Partially Reversible Causes of Dementia1

AlcoholismAnoxic brain injury

Autoimmune disordersCentral nervous system vasculitis Disseminated lupus erythematous

DepressionDrugs

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


Metabolic disordersMultiple sclerosis

NeoplasmsNormal pressure hydrocephalus

Nutritional disorders, i.e., B6, B12 deficiencyOrganic poisons, i.e., pesticides, solvents

Psychiatric disorders Trauma

Viral infections, i.e., HIV

Medications, prescription or illicit, can also cause dementia. In most cases the dementia caused by a drug is reversible, but not always. The following Table 3 lists the drugs that can cause dementia and delirium.

Table 3: Drugs That Can Cause Dementia and Delirium1

AlcoholAnalgesics

Anti-arrhythmicsAnticholinergic agents

Anti-convulsantsAntidepressants

AntihypertensivesAnti-psychotics

AnxiolyticsDigoxin


H2 receptor antagonists Non-steroidal anti-inflammatories

Sedative-hypnoticsSkeletal muscle relaxers

Steroids

There is a wide range of causes of dementia, but there are similaritiesin their clinical presentation.

Irreversible dementia is typically progressive, the signs and symptoms worsening over a course of months and years. The course is individualized with no predictability as to its pattern.

There is typically no disturbance of consciousness: the patient is awake, alert, and responsive.

Memory loss is the most prominent cognitive disability of dementia.

Impairment of language, visuospatial ability, calculation, judgment, and problem solving - what are called the executive brain functions - are also common in patients who have dementia.

Patients who have dementia often suffer from neuropsychiatric problems including, but not limited to, agitation, apathy, delusions, depression, disinhibition, hallucinations, insomnia, and wandering.

As mentioned previously, the most common causes of irreversible dementia are Alzheimer’s disease, frontotemporal dementia, Lewy body dementia, Parkinson’s disease, and vascular dementia. Some of these may not be familiar to many nurses and a brief description of each one is provided below.


Alzheimer’s Disease

Alzheimer’s disease is a chronic, progressive neurological disorder that causes severe behavioral and cognitive deterioration, especially in memory. The cause, or causes, of Alzheimer’s disease are not completely understood. Alzheimer’s disease is probably the result of a convergence of genetic risk factors and environmental stimuli that produce characteristic lesions in the parietal and temporal lobes, specifically amyloid plaques and neurofibrillary tangles. These lesions interrupt the normal metabolism and self-repair of neurons and disrupt communication between different areas of the brain.

The time from diagnosis to death can be as little as three years. The signs and symptoms of Alzheimer’s disease are difficult to treat and there is no cure.

Frontotemporal Lobe Dementia

Frontotemporal lobe dementia is a neurodegenerative disease caused by atrophy of the frontal and temporal lobe. It is a disease that is considered clinically and genetically diverse. The hallmark signs of frontotemporal dementia are behavioral and speech defects, such as expressive and fluent aphasia and abnormal personal and social behavior. In most cases the cause is unknown, however, a family history of the disease is a strong risk factor. Frontotemporal dementia is chronic, progressive, and there is no cure.

Lewy Body Dementia


Lewy body dementia is a chronic, progressive neurodegenerative disease that is characterized by the presence of Lewy bodies, abnormal deposits of protein that accumulate in neurons in specific areas of the brain. The cause of Lewy body dementia is not known. It is distinguished from other types of dementia by the Lewy bodies and by these aspects of the clinical presentation:

Varying levels of alertness and attention, especially reduced responsiveness

Visual hallucinations Parkinsonian motor signs

There appears to be some overlap of Lewy body dementia with Alzheimer’s disease and Parkinson’s disease with dementia. Lewy bodies are noted in some patients with Alzheimer’s disease (Lewy body variant of Alzheimer’s disease) and in some patients with Parkinson’s disease. Additionally, some of the signs of Parkinson’s disease with dementia and Lewy body dementia are similar. There is no cure for Lewy body dementia.

Parkinson’s Disease

Parkinson’s disease is caused by chronic and progressive destruction of dopamine-producing cells in the substania nigra area of the brain. Parkinson’s disease often causes dementia, but it is distinguished by characteristic motor symptoms such as bradykinesia (slowness of movements), gait disturbances, rigidity, and tremor.

Approximately 10% of all cases of Parkinson’s can be clearly identified as having a genetic cause, but most cases are considered to be caused by a convergence of genetic risk factors and environmental stimuli. There is no cure for Parkinson’s disease but there is effective


symptomatic treatment and the progression of the disease can be delayed.

Vascular Dementia

Vascular dementia is the second most common cause of dementia and it often coexists with Alzheimer’s disease. Vascular dementia is not a single disease; it is a group of syndromes that are caused by vascular pathologies, such as:

Cerebral infarct Cerebral hemorrhage Embolic and/or thrombotic obstructions (i.e., stroke) Various types of lesions like lacunar lesions

There are many causes of vascular dementia, and athersclerosis, diabetes, hypercholesterolemia, hypertension, and smoking are significant risk factors for the development of this pathology.

Delirium: Definition, Diagnostic Criteria And Etiology

Delirium is an acute change in mental status characterized by confu-sion and disturbances in cognition.9 Delirium is a sudden change in cognition. It develops over a short period, it fluctuates in severity, and the most prominent features of delirium are the abnormal changes that occur in attention and awareness. As with dementia, delirium is a syndrome, there are a multitude of causes, and the clinical presenta-tion can vary. Delirium is usually transient and reversible, but delirium can persist for hours or days (acute) or weeks or months (persistent), and it is associated with high rates of morbidity and mortality. The DSM-5 criteria for delirium are:9

Delirium: DSM-5 Diagnostic Criteria


1. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).

2. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline atten-tion and awareness, and tends to fluctuate in severity during the course of a day.

3. An additional disturbance in cognition (i.e., memory deficit, dis-orientation, language, visuospatial ability, or perception).

4. The disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive dis-order and do not occur in the context of a severely reduced level of arousal, such as coma.

5. There is evidence from the history, physical examination, or lab-oratory findings that the disturbance is a direct physiologi-cal consequence of another medical condition, substance intoxi-cation or withdrawal (i.e., due to a drug of abuse or to a medica-tion), or exposure to a toxin, or is due to multiple etiologies.

When making the diagnosis of delirium it must be specified if the delirium is hyperactive, hypoactive, or involves a mixed level of activity, and associated with the following symptoms.

Hyperactive:

The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or re-fusal to cooperate with medical care.


Hypoactive:

The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that ap-proaches stupor.

Mixed level of activity:

The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes in-dividuals whose activity level rapidly fluctuates.

A hyperactive level of psychomotor activity characterizes hyperactive delirium, and is it seen in patients who are intoxicated or in withdrawal from drugs such as amphetamine or phencyclidine. A decreased level of psychomotor activity characterizes hypoactive delirium, and the pa-tient 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 medi-cations are an important and common cause of delirium. Dementia is also a very common cause of delirium. Delirium can happen to any pa-tient, but it is more prevalent in the elderly.

It is not clear if advanced age itself is a risk factor for delirium. How-ever, the elderly patient population often has greater exposure to iden-tified risk factors for delirium; bladder catheterization, decreased abil-ity to metabolize and eliminate medications, dementia, fracture, hear-


ing impairment, immobility, inadequate or excessive use of analgesics or sedatives, malnutrition, multiple medications, pre-existing demen-tia, sensory deprivation, status-post anesthesia and surgery, underly-ing medical or neurologic illnesses, use of physical restraints, and vis-ual impairment.1,5,9 Common causes of delirium are listed in Table 4 be-low.

Table 4: Common Causes of Delirium1,8

Acute blood loss Acute myocardial infarction

Acute psychosesAzotemia

Congestive heart failureDecreased cardiac outputDecreased sensory input

DehydrationDementia

DrugsDrug overdose

Drug withdrawalDehydration

Fecal impactionFracture

IntoxicationHypercarbia

Hypo- or hyperglycemiaHyponatremia

Hypo- or hyperthermiaHypoxia

ImmobilityInfections

MalnutritionMetabolic disorders


Post-Operative StateParkinson’s disease

Stroke (small cortical)Urinary retentionVisual impairment

Delirium is often misdiagnosed and it may be mistaken for dementia, depression, another psychiatric disorder, or attributed to old age.9 This underrecognition can delay treatment, and it can also prolong the du-ration of delirium and expose the patient to permanent neurological damage.5

Mild Cognitive Impairment And Pseudo-dementia

Mild cognitive impairment (MCI) and pseudo-dementia should also be mentioned when discussing dementia. Individuals who have MCI or pseudo-dementia can often develop dementia. MCI is often overlooked, and pseudo-dementia is often misdiagnosed as dementia.

Mild cognitive impairment is a term used to describe cognitive deficits that are not considered to be a normal part of aging but do not fit the diagnostic criteria for dementia.10,11 There are differences in the diag-nostic criteria for MCI and these criteria are not precise, but MCI is gen-erally considered to be an intermediate state between normal cogni-tive functioning and dementia. In their 2014 review, Langa, et al., used these criteria for the diagnosis of MCI.10

Concern regarding a change in cognition from the patient, knowledgeable informant, or from a skilled clinician ob-serving the patient.


Objective evidence of impairment (from cognitive testing) in 1 or more cognitive domains including memory, execu-tive function, attention, language, or visuospatial skills.

Preservation of independence in functional abilities (al-though individuals may be less efficient and make more er-rors 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 occu-pational 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 ac-tivities of daily living.10,11 The patient who has MCI is aware of the change in his/her memory, unlike the person who has dementia. Mild cognitive impairment may be temporary and a reversion to normal mental status is possible12 but approximately 5%-20% of people who have MCI will develop dementia.10

Pseudo-dementia is a descriptive term for a clinical presentation that closely mimics dementia, but is usually caused by depression and oc-casionally by other psychiatric disorders.13,14 Depression in the elderly can cause many of the cognitive defects that are common to demen-tia.

Dementia can produce depressive signs and symptoms14 so a misdiag-nosis is relatively common. Some key differences between dementia and depression are:6

Depression has a relatively abrupt onset but the onset of demen-tia is slow.

Dementia progresses while depression plateaus.


Patients who are depressed often know they are depressed and will complain of their problem. Patients who have dementia are seldom aware of their condition.

The affect and emotions of people who have dementia are vari-able. 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 of-ten an unreliable source of informa-tion. Confirmation of the diagnosis of dementia using imaging studies, lab-oratory tests, and/or specific physi-cal findings may not be possible. Also, some patients may have more than one cause of dementia. The di-agnostic process is time consuming and it is not uncommon for demen-tia to be mis-diagnosed.4 The incidence of a missed diagnosis of de-mentia has been reported to be as high as 50%-80%, depending on the severity of the case and who is doing the assessment.15

The specific diagnostic approach, i.e., what tests should be ordered, will differ depending on the suspected cause of dementia. But the as-


sessment process outlined below can be applied to any situation in which dementia may be present. Vital Signs

Assessment of the airway, breathing, and circulation (ABCs) and body temperature is always the first step of a patient assessment. Abnor-malities of blood pressure, pulse, and temperature can provide valu-able indicators about the source of dementia. For example, hypother-mia 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 re-viewed, either by speaking to the patient, family members, friends, or caretakers. The reviewer should ask specific questions about behavior, changes in social circumstances, daily activities, elimination patterns, food and fluid intake, and mood. It is important to learn whether there have been any recent events such as an accident, illness, trauma, or surgery that could be a cause of delirium. The reviewer should also de-termine if the neuropsychological changes have been slow or sudden in onset and how quickly they have progressed as this information can provide valuable clues about the etiology of dementia.16,17

Family/Significant Other Interview

A careful interview of family members/significant others and caretakers is a necessary part of patient evaluation because the patient who has dementia will seldom be aware of the changes in cognition and mem-ory. The interviewer should ask specific questions about the patient’s day-to-day life:

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


Has there been wandering behavior or dangerous driving? Has the patient had difficulty sleeping? Has the patient’s personal hygiene deteriorated or has he/she

been incontinent?

Galvin, et al., found that the following eight question interview was sensitive and specific for detecting dementia and cognitive impair-ment.18 Has the patient shown any of the following deficits or behav-iors?

Problems with judgment Reduced interest in activities or hobbies Repeating questions, stories, or statements Trouble learning how to use an appliance or tool Forgetting what month or year it is Unable to handle simple financial affairs Forgetting appointments Consistent problems with memory and/or thinking

Medical and Surgical History

The patient’s medical and surgical history should be be carefully re-viewed. This review should include the medical history of the patient’s immediate family, i.e., parents and siblings. Asking about alcohol or drug abuse can be uncomfortable but it should be done; and, it is often helpful to review the patient’s history of alcohol or drug abuse with someone other than the patient.

Medication History


When reviewing the patient’s health history a current list of the pre-scription medications the patient is taking should be obtained and veri-fied 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 deter-mined if the patient has been taking his/her medications as prescribed. There may have been an inadvertent or intentional overdose, the pa-tient may have been skipping doses, or he/she may have simply stopped taking a prescribed medication.

Physical Assessment

A comprehensive physical examination should be performed. The find-ings may be equivocal and/or non-specific, but the presence of some physical findings and the absence of others can help the clinician de-cide which diagnostic tests should be done and suggest the cause of the dementia. For example, bradykinesia and gait disturbances are characteristic of Parkinson’s disease, the presence of papilledema sug-gests that the patient may a brain tumor or a subdural hematoma, and myoclonus can indicate the presence of human immunodeficiency virus (HIV)-related dementia.7

Laboratory Tests, Imaging Studies, Other Diagnostic Tools

There are no laboratory tests, imaging studies, or other diagnostic tools that should be routinely performed for every patient who is sus-pected of having dementia.4,16 The physical examination and history taking should determine what is needed, and it is important to focus di-agnostic efforts in order to avoid unnecessary procedures and delays in making the diagnosis.


Laboratory tests that are helpful when determining the cause or pres-ence of dementia include complete blood count (CBC), blood urea ni-trogen (BUN) and creatinine, serum calcium and phosphorus, pulse oximetry, serum glucose, serum electrolytes, liver function tests, thy-roid studies, vitamin B12 level, 12-lead ECG, and (possibly) testing for HIV antibodies.16 The American Academy of neurology suggests that at a minimum laboratory tests for determining the cause of dementia should include CBC, electrolytes, renal and thyroid function studies, a vitamin B12 level, and a neuro-imaging study such as a computerized tomography (CT) scan or a magnetic resonance imaging (MRI) scan.16

The use of neuro-imaging studies such as CT or MRI - especially MRI - can be used to determine the specific type of dementia, to evaluate the progress of neurological damage, and possibly predict who will de-velop dementia.16,19,20 For example, medial temporal lobe atrophy is common in patients with dementia, but it is usually more pronounced, and the pattern of injury different, in patients who have Alzheimer’s disease; and, cerebral infarcts may be seen in patients who have vas-cular dementia.19

Neurologic and Psychiatric Assessment

A careful assessment of the patient’s neurological and psychiatric sta-tus is the crucial part of the evaluation for the presence of dementia. There is much information that can be acquired by simple observation. When the clinician is examining or interviewing the patient, it is impor-tant to pay special attention to:7,16,17

Alertness/level of consciousness: Whether the patient is paying attention and responding to their surroundings

Aphasia:


Inability to express or understand language, spoken or written Apraxia:

Inability to perform physical tasks that the patient has the capa-bility of doing

Behavior: Erratic or inappropriate behavior in the patient, observed or re-ported

General appearance Memory:

How well the patient retains and recalls information Mood:

Unexplained mood swings in the patient, observed or reported Orientation:

Whether the patient knows the date and time Thought process:

Organized or disorganized thinking

The clinician should also carefully observe the patient for:1

Executive functioning, i.e., planning, weighing alternatives, coor-dination 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 un-

derstands 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, in-telligence, or visuospatial ability. For example, memory can be tested using the Constructional Praxis Test and using the clock test can as-sess visuospatial ability. Neuropsychological tests are lengthy and complex and they can be helpful when the initial assessment shows a cognitive deficit but the specific problem causing the cognitive deficit is not obvious. These tests are considered to have a relatively high sensitivity and specificity for detecting dementia,4 and can be useful in differentiating dementia from depression.1

Standardized screening tests can be helpful to assess for the presence and severity of dementia, but it should be remembered that these are used for screening; they are not diagnostic nor are they a substitute for a comprehensive mental status examination; they may not detect early stage dementia, and; they cannot differentiate between different types of dementia.16,17 Nonetheless, these screening tests are widely used and a familiarity with them is important.

Five screening tests that are commonly used are the Mini-Mental State Examination (MMSE), the Mini-Cog, The Clinical Dementia Rating (CDR) scale, Addenbrooke’s Cognitive Examination - revised (ACE-r), and the Montreal Cognitive Assessment (MOCA). There are many other assess-ment tests/tools and a full discussion of each one and their limits, strengths, and how and when they should be used is beyond the scope of this module but several will be reviewed here. In depth information on dementia screening tests is available in the 2015 review by Tsoi, et al. (2015),21 the 2014 review by Yokomizo, et al.,15 and a 2013 review by Lin, et al.22


Mini-Mental Status Exam

The Mini-Mental Status Exam (MMSE) is commonly used. It can be done relatively quickly, and it is the most widely studied of the cognitive screening tests.4 The test is not considered to be sensitive for mild de-mentia and performance may be affected by age and level of educa-tion.4

The MMSE involves performance of the following tasks:

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

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

Name three objects:

Name three objects and then ask the patient to repeat them. Give one point for each correct answer. Repeat them until he/she learns all three. Count and record the number of trials. The first repetition determines the score, but if the patient cannot learn the words after six trials then recall cannot be meaningfully tested: Maximum score is 3 points.

Serial 7s:

Ask the patient to count backwards in increments of 7, starting with the number 100. One point for each correct answer; stop af-ter 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 cor-rect: Maximum score is 3 points.


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

Repeat the following: "No ifs, ands, or buts." Allow only one trial - 1 point.

Follow a three stage command, "Take a paper in your right hand, fold it in half, and put it on the floor." Score one point for each task executed: Maximum score is 3 points.

On a blank piece of paper write "close your eyes." Then ask the patient to read and do what it says - 1 point.

Give the patient a blank piece of paper and ask him/her to write a sentence. The sentence must contain a noun and verb and be sensible - 1 point.

Ask the patient to copy a design (i.e., intersecting pentagons). All 10 angles must be present and two must intersect – 1 point.

The maximum score on the MMSE is 30 points. A score of less than 24 points is usually considered to be suggestive of dementia or delirium.4 Mini-Cog

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

The names of the three objects (i.e., banana, car, dog) are given to the patient and he/she is then asked to repeat them. After that, the patient is asked to draw the clock and when that task has been completed, he/she is asked to tell the interviewer the names of the three objects. Each correctly recalled word is worth one point and the clock is consid-ered normal if the time is correct and the clock is grossly normal.


Dementia is present if the score is 0 or if the patient recalls 1-2 words and the clock is abnormal. If the patient recalls 1-2 words and the clock is normal or if the patient recalls all 3 words, there is no dementia. The Mini-Cog is very quick to administer. It takes approximately three min-utes to complete and it is considered to be very sensitive for detecting dementia.4

Clinical Dementia Rating

The Clinical Dementia Rating (CDR) was designed to assess the sever-ity of Alzheimer’s disease. It is rather lengthy to administer and it de-pends to a degree on the subjective observations of the test adminis-trator, but it has been shown to be valid and sensitive.4

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

Community affairs Home and hobbies Judgment Memory Orientation Problem solving

The patient is judged on his/her abilities and performances in these ar-eas as follows:

0 = None 0.5 = Very mild 1 = Mild 2 = Moderate


3 = Severe

The ratings and interpretations are: 0 = Normal 0.5 to 4 = Questionable cognitive impairment 4.5 to 9 = Mild dementia 9.5 to 15.5 = Moderate dementia ≥ 16 = Severe dementia

Montreal Cognitive Assessment (MOCA)

The Montreal Cognitive Assessment (MOCA) has been shown to be a useful screening tool for detecting MCI and detecting MCI in patients who have Alzheimer’s disease,23,24 for identifying people with cognitive impairment who are at risk for developing dementia,25 and identifying patients who have dementia.26,27 The patient is assessed in 10 areas of cognitive ability, i.e., attention, memory, and sentence repetition and the test takes approximately 10 minutes to administer. A complete ex-ample of the MOCA will not be presented here, as it is quite lengthy; and, the reader is recommended to pursue additional information on-line at the mocatest.org website.

Assessment Of Delirium

In many cases delirium is a clinical diagnosis that cannot be confirmed by imaging studies, laboratory tests, or specific physical findings and determining whether the patient does, or does not have delirium will depend on thorough history taking and patient assessment. The as-sessment process outlined below can be applied to any situation in which delirium may be present.

Vital Signs


Assessment of the airway, breathing, and circulation (ABCs), and body temperature is always the first step of a patient assessment. Hypo- and hyperthermia, hypoxia, hyper- and hypotension, bradycardia, tachycardia, respiratory depression and tachypnea can be signs of causes of delirium. Some causes of delirium include blood loss, conges-tive heart failure, dehydration, drug overdose, infection, and myocar-dial infarction.

History

The events in the patient’s life prior to the onset of delirium should be reviewed, either by speaking to the patient, family members, friends, or caretakers. The clinician should ask specific questions about behav-ior, changes in social circumstances, daily activities, elimination pat-terns, food and fluid intake, and mood. It is important to learn whether there have been any recent events such as an accident, illness, trauma, or surgery that could be a cause of delirium.

Medical and Surgical History

The patient’s medical and surgical history should be carefully re-viewed. This review should include the medical history of the patient’s immediate family, i.e., parents and siblings. Similar to the history tak-ing with dementia, the history should include a thorough investigation into the patient’s use or abuse of substances. Since she/he may not be forthcoming or unable to inform the interviewer about the history of substance abuse, it may be necessary to ask someone other than the patient about the patient’s use of alcohol and/or illicit drugs.

Medication History


A current list of the prescription medications the patient is taking and verification of new medications recently prescribed or changes in dos-ing is important. The clinician should inquire about the use of over-the-counter and/or herbal medications. It is important to determine if the patient has been taking his or her medications as prescribed. There may have been an inadvertent or intentional overdose, the patient may have been skipping doses, or he or she may have simply stopped taking a prescribed medication.

Physical Assessment

A physical examination can be difficult or impossible to perform if the patient is agitated, confused, or uncooperative. If it is not possible to do a complete physical examination then the clinician should do a par-tial examination in stages and gather as much information as possible by observing the patient.

Findings from a physical examination in situations where the patient may be unable to cooperate may be equivocal. However, the presence of some physical findings and the absence of others can help the clini-cian decide which diagnostic tests should be done and can suggest the cause of the delirium. For example, the patient who has had a stroke may have hemiparesis or a patient who is dehydrated will have dry mucous membranes and decreased skin turgor.

Laboratory Testing, Imaging Studies, Other Diagnostic Tools

There are no laboratory tests, imaging studies, or other diagnostic tools that should be routinely performed for every patient who is sus-pected of having delirium. The physical examination and history taking should determine what is needed, and it is important to focus diagnos-


tic efforts in order to avoid unnecessary procedures and delays in mak-ing the diagnosis.

Basic tests that are helpful when assessing for the presence of delirium are the CBC, creatinine, serum calcium, electrolytes, and glucose, arte-rial blood gas, 12-lead ECG, and urinalysis and urine culture. Drug lev-els of medications such as digoxin and lithium should be done if appro-priate. Neuro-imaging should be done if there is no obvious cause of delirium.8

Neurological and Psychiatric Assessment

As with the physical examination, a complete neurological and psychi-atric evaluation may not be possible if the patient is agitated, con-fused, or uncooperative. When evaluating a patient for the presence of delirium, carefully observe these areas of cognition and behavior:1,8

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


Visuospatial functions, i.e., how well the patient analyzes and un-derstands space in several dimensions

The signs and symptoms of delirium include:1,8

Agitation Anxiety Apathy Delusions Difficulty with language and speech Disorientation Distractibility Drowsiness Dysarthria Dysphasia Emotional lability Flight of ideas Fluctuating level of consciousness Hallucinations Illusions Inability to concentrate or focus Memory loss Perceptual disturbances Restlessness Sleep disturbances Tremor

Standardized screening tests can be used to detect delirium. One of the oldest and most commonly used in the Confusion Assessment Method (CAM).8 The CAM has been shown to be accurate and reli-able.8,28 It is easy to administer and it can be used in a wide variety of


clinical situations but it does require considerable training to use cor-rectly.28

The CAM compares well to other delirium screening tests, but it should be remembered that no screening test is perfect for detecting delir-ium.29,30

The CAM has two parts: the first is an assessment tool that is used to detect cognitive impairment and the second is a short screening test that is used to distinguish delirium from dementia. Part two is pre-sented here, in Table 5. The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.31

Table 5: The CAM Screening Test Part 2

1. Acute onset and fluctuating course Is there evidence of an acute change in mental status from the patient’s baseline? Did the abnormal behavior fluctuate during the day, i.e., tend to come and go, or increase and decrease in severity)?

2. Inattention Did the patient have difficulty focusing attention (i.e., being easily distractible) or have difficulty keeping track of what was being said?

3. Disorganized thinking Was the patient’s thinking disorganized or incoherent? Did he/she have rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

4. Altered level of consciousness


How would you rate this patient’s level of consciousness? Alert (normal), vigilant (hyper-alert), lethargic (drowsy, easily aroused), stuporous (difficult to arouse), or coma (unarousable). If the patient’s level of consciousness is anything other than alert, that should be considered a positive score.

Nursing Care Of The Patient With Dementia

Nursing care and treatment of the patient who has dementia should focus on:

Communication Neuropsychiatric behavioral issues Safety and comfort Pain Control Medication used to treat dementia

Communication

The patient who has Alzheimer’s disease, vascular dementia, or any pathology that causes dementia will have problems in using and understanding language. The patient may have difficulty understanding what is said, expressing ideas and emotions, and responding appropriately.32 Hearing and speech impairments may be present and depression may negatively influence the patient’s desire to communicate.


Limitations of the patient with dementia do not mean the patient needs to be isolated or that the nurse cannot have clear and meaningful communication with the patient. The keys to overcoming limitations are assessment and adjustment.

The nurse caring for the dementia patient needs to assess the patient’s communication abilities and needs and then adjust to his or her communication style. If the nurse can do this, the interactions between the nurse and the patient will be effective and satisfying. This is done on an individual basis but there are some simple principles the nurse should always keep in mind when communicating with a patient who has dementia.

Communication problems associated with dementia do not correspond to a loss of self-identity and studies show that the personality endures despite these communication difficulties.33,34 When a caregiver acknowledges a patient’s self-identity, the patient’s disruptive and combative behavior is often dissipated. The challenge for caregivers is to discover the patient’s self-identity.

Families and caregivers develop effective personalized communication patterns with patients35 and it can be very helpful to ask them how they communicate with the patient.

Reality orientation is a helpful communication strategy. It involves constant, repetitive verbal and visual clues to keep the


patient oriented. This technique can improve functional abilities in patients who have dementia.36,37 Potential scenarios would be that the nurse introduces themself each time they talk to the patient, points to calendars and clocks frequently in conversation, and talks about current events and the plans for the day.

Speaking clearly and slowly is important in the facilitation of meaningful and successful conversation with the patient who has dementia. Remember to make eye contact and use short sen-tences. Waiting for responses and not answering for the patient is another helpful strategy; avoid finishing sentences for the pa-tient or interrupting the patient.

If the patient cannot answer or respond correctly at first, the nurse should try again. Being aware of one’s tone and volume of voice and of body language is important. Minimizing distractions when communicating with the patient with dementia and avoid-ing several conversations at the same time will help the patient’s effort to communicate.

The Alzheimer’s Association publishes a guideline on communi-cating with patients who have dementia that outlines some of these strategies (accessible at alzheimers.org).

Neuropsychiatric Behavioral Problems

Neuropsychiatric behavior problems are a common and serious complication of dementia.38-40 Agitation, aggression, anxiety, apathy, delusions, depression, disinhibition, hallucinations, inappropriate behavior, sleep disturbances, and wandering occur quite often and they are disturbing for patients and caregivers. They are also


potentially dangerous and if not properly managed, they can increase the incidence of morbidity and mortality and increase length of hospital stay.

It is often assumed that these problems are simply part of dementia and dementia does contribute to their development, their intensity and how and when they occur. However, the cause of and initiating factors for agitation, aggression, inappropriate actions and speech, and other neuropsychiatric behavioral problems is almost always internal and/or external stimuli that are not obvious to family members, caregivers, and health care professionals.41

The patient who has dementia frequently has cognitive deficits that affect his or her ability to cope, communicate, and provide self-care, and neuropsychiatric behavior problems are simply a response to stress. It is important for the caregiver or clinician to evaluate stressors and the patient’s response to stressors. Considering neuropsychiatric behavior problems as “normal” for a patient who has dementia is in one sense treating the patient as less than whole.

It is recommended that behavioral and environmental approaches should be used to treat neuropsychiatric behavior problems before pharmacological intervention.38,42,43 Medications should only be used in these situations if:

Non-pharmacologic interventions have failed. The patient has major depression with or without suicidal

ideation. The patient has a psychosis that is causing great harm or has the

potential to do so. The patient is very aggressive and may harm himself/herself or

others.


DICE Method

The optimal approach to neuropsychiatric behavior problems can be summarized as making every effort to understand the situation from the patient’s point of view. A recommended method is the DICE approach: Describe, Investigate, Create and Evaluate.44 This is a systematic way of identifying and treating neuropsychiatric behavior problems that operates with the assumption that such behavior problems are caused by a stressor that can be identified and corrected and that these issues can be solved with creativity and patience.

Describe

In the first step of the DICE method the clinician is exploring such questions as:

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

Who was the patient interacting with or near to when the agitation occurred?

What are the environmental conditions, the time of day? What was the patient doing immediately before the agitation

began? Is the patient complaining and if so, about what?

Investigate

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


Was the patient recently given a medication or is he or she scheduled for a dose?

Was the patient recently started on a medication? Has the patient been incontinent or could he or she be in pain? Has the patient’s daily activity schedule been changed or his or

her sleep pattern been disrupted? What are the patient’s vital signs?

When performing this investigation it is important to remember that many people who have dementia are elderly and have chronic medical problems. Neuropsychiatric behavioral problems are often caused by emotional or psychological stress, but the possibility of an acute illness or exacerbation of an existing one should always be considered.

Create

Creating a treatment plan should be a collaborative effort between nurses, other healthcare professionals and if they are involved in day-to-day care, the family members. The clinician needs to focus on the behavior that is problematic at the time, but also on root cause and prevention. Strategies for the two can be different. The patient who is agitated may need to be in a place that is quiet and away from others - an immediate solution - but underlying causes such as over-stimulation and pain need to be addressed.

Evaluate

In this final step, the clinician is evaluating the strategy in terms of negative and positive consequences and how easy it was to apply.


Safety And Comfort Of The Patient With Dementia

Safety and comfort are very important areas of care. The patient who has dementia has a decreased capacity for decision making and may also have limited physical capabilities. Those factors increase the risk for accidents, errors in judgment, falls, and other forms of harm.

Discomfort is a common source of behavioral problems for the patient who has dementia. He or she may be unable to communicate about discomfort or take actions to relieve discomfort and this can lead to behavioral problems such as agitation or wandering. Assessment and re-assessment of the patient and his or her environment must be done frequently, and the clinician should always be evaluating whether the patient is safe and comfortable.

Pain Control

Pain is very common in patients who have dementia and it is often under-recognized and under treated.45-47 Patients who have dementia do not experience any less pain than older adults without dementia, but assessment for pain in this patient population is challenging. Patients who have dementia may not interpret sensations as painful, have difficulty recalling pain in the recent past, and may be unable to tell someone about their pain. In addition, the patient who has dementia may be prescribed analgesics, antipsychotics, or other medications that can blunt their response to pain. Untreated pain can cause behavioral problems and psychological distress,45 and untreated pain in any patient is unacceptable.

In many patient care situations assessment for the presence of pain and evaluating the success of treatments for pain depends in large


part on self-reporting: the patient will tell us how much pain he or she is having and if the interventions provided relief. But for the patient who has dementia this is often not an option. Nurses and other healthcare professionals will need to use professional judgment and an assessment tool.

There are many pain assessment tools available, but it is not clear which ones are best for this clinical application. Recent reviews by Corbett, et al. (2014) and Husebo, et al. (2016; 2014; 2010) of pain assessment tools utilized when assessing patients with dementia noted that the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) pain assessment tool is useful and reliable45,47-49 and the MOBID-2 has “... high-to-excellent reliability and aspects of validity”.45

The MOBID-2 is very reliable for detecting the presence of pain in patients who have dementia and could also be used to assess the response to pain treatments.45 The MOBID-2 uses the patient’s observed responses (facial expression, aversive/defensive behavior, and noises indicating the presence of pain) to five simple physical tasks, i.e., stretching both arms towards the head; and, observations by the nurse or other caregiver of patient behavior during normal daily activities that may indicate the presence of pain.49

The choice of pain medication should be guided by the clinical situation. There are few controlled studies that have assessed the use of analgesics for this patient population. Husebo, et al. (2016) reviewed the available literature and found the evidence was strongest for the use of acetaminophen; there was very little data on the use of opioids; and, there are no controlled studies on the use of codeine, non-steroidal anti-inflammatories, or tramadol.47


Medications Used to Treat Dementia

Non-pharmacologic treatments should be the first line therapies for treating patients who have dementia and have behavioral issues such as agitation and anxiety but these may not always be effective. The primary drugs that are used to treat problematic behaviors in this patient population are the cholinesterase inhibitors and memantine.

The drugs most commonly used to treat dementia are the cholinesterase inhibitors.50,51 The three cholinesterase inhibitors currently available in the U.S., that have a labeled use for the treatment of dementia of Alzheimer’s disease are donepezil, galantamine, and rivastigmine. Cholinesterase inhibitors inhibit the activity of cholinesterase at the synaptic cleft and increase cholinergic transmission. Patients who have Alzheimer’s disease have a decreased cerebral synthesis of acetylcholine, but the cholinesterase inhibitors are also used to treat vascular dementia, Lewy body disease, frontotemporal dementia, and other forms of dementia.

The cholinesterase inhibitors can produce a mild improvement in cognition and increase the ability to perform activities of daily living, and they may delay progression of cognitive defects.50 The long-term benefits of the use of cholinesterase inhibitors for patients who have dementia is still being determined, and it is not known which patients who have dementia should be prescribed these drugs and what the optimum duration of therapy is.50 Regardless, most sources recommend a trial period of cholinesterase inhibitors and donepezil, galantamine, or rivastigmine can be used; they appear to be equally effective.50 The dose should be slowly titrated and at the end of eight weeks of the maximum dose the patient should be reassessed. If there is no improvement, the drug should be stopped.50


Donepezil, galantamine, and rivastigmine are available as oral tablets, solution, sustained-release capsules, and transdermal patch. Because of their mechanism of action, gastrointestinal effects such as diarrhea, nausea, and vomiting are very common. Agitation, ataxia, dizziness, headache are also common adverse effects.

Memantine is an N-methyl-D-aspartate (NMDA) receptor antagonist. N-methyl-D-aspartate is a neurotransmitter that mimics the action of glutamate, one of the major excitatory neurotransmitters. Memantine has a labeled use for the treatment of moderate to severe dementia associated with Alzheimer’s disease and an unlabeled use for the treatment of mild to moderate vascular dementia. Used alone or with cholinesterase inhibitors, memantine helps improve cognition and performance of activities of daily living, and it may slow progression of the disease.52 Common adverse reactions effects of memantine include confusion, dizziness, and headache. The drug is available as oral tablets, solution, and extended-release capsules.

The use of antipsychotics for treating behavioral problems associated with dementia is somewhat controversial. Brasure, et al., in their 2016 review write that the antipsychotic medications “... have limited efficacy and significantly increase the risk of stroke and mortality. For some individuals with dementia, side effects of antipsychotic medications can lower quality of life.”38 Greenblatt, et al. (2016) however note that the conventional and atypical antipsychotics “... appear to have modest to moderate clnical efficacy in the treatment of these symptoms.”53 Both of these authors acknowledge the increased risk of mortality associated with the use of antipsychotics in this patient population but the opinion of the risk by Greenblatt, et al., appears tempered: “... the observed risk increase


may be partially confounded by illness severity and/or preexisting health determinants”.53 However, Greenblatt, et al., do caution that the dose and duration of therapy of these drugs should be minimized and that patients shhould be continuously monitored for adverse effects.

Press and Alexander (2016) point out that the antipsychotics do not have a labeled use for treating behavioral disorders in patients with dementia, and their preference is to administer these drugs only if the patient is having severe behavioral problems and other approaches or medications are not effective.54

The benzodiazepines may seem to be a logical choice for treating behavioral problems associated with dementia, but they should not be routinely used in these clinical situations.55 There is limited evidence for their benefit and the adverse effects and risks of their use are considerable.54,55

Depression is best treated with a selective serotonin reuptake inhibitor.54 These drugs should be used cautiously for patients who have dementia however, and there is little evidence of their efficacy for treating depression in patients who have dementia.56-58 Other medications that have been used to treat patients who have dementia, either for symptomatic relief or as preventative measures include: estrogen, folic acid, gabapentin, gingko biloba, lamotrigine, melatonin, metylphenidate non-steroidal anti-inflammatories, selegiline, statins, trazodone, valproate, vitamin B6, vitamin B12, and vitamin E.1,54 At this time, there is either no evidence or very limited evidence that any of these drugs, supplements, or vitamins are effective.1,54

Other Therapies and Interventions


Cognitive rehabilitation, formalized exercise programs, and occupational therapy are relatively risk-free interventions that have been shown to be of benefit for patients who have dementia.42

Delirium: A Medical Emergency

Delirium is considered to be a medical emergency. Therapies and interventions that would be appropriate when treating most patients who have delirium would be:59,60

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

be a problem for patients who have delirium. Re-orientation techniques Bedside sitter If possible and if it helps, close contact with a family member or

someone familiar to the patient is encouraged. Make sure the patient has his or her corrective lenses and/or

hearing aid if they use these. Maintain normal sleep patterns. Assess for and treat pain.

Non-pharmacologic interventions should always be the first-line choice for patients who have delirium.59 Physical restraints should not be used unless other interventions have failed and there is risk to the patient or others.59 Antipsychotics can be used to treat severe agitation in patients who have delirium, but they do have significant side effects and there is little data that supports their use for the treatment of delirium.59

The standard pharmacological therapy for treating patients who have delirium and who do not respond to non-pharmacological interventions is haloperidol.59 Haloperdiol and the atypical antipsychotics olanzapine,


quetiapine, risperidone ziprasidone have all been shown to be effective in treating delirium.59-61 Drowsiness, hypotension, and extrapyramidal effects are common adverse effects of the antipsychotics. Benzodiazepines are useful if the delirium is caused by alcohol or drug withdrawal,59 but in other types of delirium they may worsen the patient’s confusion and cause sedation.

Summary

Dementia and delirium are neurological disorders that cause signficant cognitive impairment and increase the risk of morbidity and mortality. These diseases can be difficult to detect and diagnose. Some cases of dementia and many cases of delirium are reversible, but dementia is most often chronic, progressive, and cannot be cured; and, the dementias and deliriums that are considered reversible may result in serious complications. The most common cause of dementia is Alzheimer’s disease. Medications and dementia appear to be the most common causes of delirium.

Advanced age itself is not a cause of either disease, but the elderly do have a high risk for developing dementia and delirium and as the U.S., population continues to get older, the incidences of dementia and delirium are likley to increase. Treatment of dementia and delirium is primarily symptomatic and supportive unless there is a clearly identified etiology. Primary concerns when providing nursing care for the patient who has either dementia or delirium are: monitoring of vitals signs, behavioral and environmental interventions, safety and comfort, pain control, and safe administration of medications.


Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.1. One of the defining characteristics of dementia is

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


a. trauma and heavy metal poisoning.b. infections and hemorrhage.c. Alzheimer’s disease and vascular pathologies.d. hypoxia and Parkinson’s disease.


a. movement disorders and a progressive cognitive decline.b. attention deficits and confusion. c. expressive aphasia and hypotension.d. hyperthermia and depression.



a. acute.b. slow.c. chronic.d. fluctuating.


a. Parkinson’s disease and advanced age.b. drug withdrawal and Lewy body dementia.c. acute blood loss and frontotemporal dementia.d. drugs and dementia.

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

a. Trueb. False

7. The onset of neurologic changes of dementia are usually

a. acute.b. slow and progressive.c. chronic.d. fluctuating and regressive.

8. Use physical restraints with patients who have dementia

a. if the patient is agitated or confused. b. when there is a significant risk for a fall.c. if all other interventions fail and there is a serious risk of

harm.d. if the patient is likely to wander.

9. Neuropsychiatric behavior problems in patients who have dementia

a. are caused by an external or internal stimulus.b. typically occur randomly and without cause. c. only occur if patients are over-medicated.d. happen primarily at night.


10. The use of antipsychotics for treating patients who have dementia

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

inhibitors. c. can reverse the progress of dementia.d. is questionably effective and potentially dangerous.

11. The drug most commonly used to treat agitation in pa-tients who have delirium is

a. diazepam.b. haloperidol.c. galantmine.d. bupropion.

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

a. Trueb. False

13. Benzodiazepines are

a. the first-line treatment for dementia or delirium.b. absolutely contraindicated for dementia or delirium.c. seldom useful and may worsen dementia or delirium. d. only useful if used together with antipsychotics.

14. Which of the following is commonly used to treat demen-tia?

a. Fluvoxamine.b. Lithium.c. Methylphenidate.d. Rivastigmine.


a. Memantine.


b. Nortriptyline.c. Carbamazepine.d. Diphenhydramine.

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

a. are specific to a single age group.b. cannot be eliminated or cured.c. can have many different causes.d. is a major cognitive disorder.

17. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) has replaced the term dementia with the term

a. major/mild cognitive disorder.b. major/minor cognitive deficit.c. dementia syndrome.d. neurocognitive syndrome.

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

a. Only with major cognitive disorderb. With major or mild cognitive disorderc. When mental illness (e.g., schizophrenia) is not presentd. Only with minor cognitive disorder

19. Dementia can be usefully divided into two categories:

a. dementia syndrome and senior dementia.b. unspecified and specified.c. cognitive disorder and cognitive deficit.d. reversible and irreversible.

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

a. Trueb. False


21. Which of the following is NOT able to cause irreversible de-mentia?

a. Degenerative diseases of the nervous systemb. Traumac. Vascular disordersd. None of the above

22. In most cases, dementia caused by _______________ is re-versible but not always.

a. carbon monoxide poisoning b. agingc. a drugd. hypoxia

23. Drugs that can cause dementia and delirium include:

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

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

a. lesionsb. protein depositsc. destruction of dopamine-producing cellsd. thrombotic obstructions

25. Frontotemporal lobe dementia is a neurodegenerative dis-ease caused by _____________ the frontal and temporal lobe.

a. thrombotic obstructions ofb. atrophy ofc. protein deposits ind. All of the above

26. ____________________ is a chronic, progressive neurodegenera-

tive disease that is characterized by the presence of ab-normal deposits of protein that accumulate in neurons in specific areas of the brain.

a. Lewy body dementiab. Frontotemporal lobe dementiac. Parkinson’s disease


d. Vascular dementia

27. Patients who have dementia often suffer from neuropsy-chiatric 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. Trueb. False

29. In Alzheimer’s disease, lesions in the parietal and tempo-ral 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 speci-fied if it is hyperactive, hypoactive, or involves a mixed level of activity.

a. Parkinson’s diseaseb. vasculitisc. dementia d. delirium

31. ___________ is an acute change in mental status character-ized by confusion and disturbances in cognition.

a. Hypoxiab. Vasculitisc. Dementiad. Delirium

32. Parkinson’s disease’s characteristic motor symptoms are similarly found with __________________ patients.

a. Lewy body dementia


b. Alzheimer’s diseasec. frontotemporal dementiad. vascular dementia

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

a. thrombotic obstructions.b. behavioral and speech defects.c. visual hallucinations.d. expressive and fluent aphasia.

34. The hallmark signs of frontotemporal dementia are

a. visual hallucinations.b. Parkinsonian motor signs.c. behavioral and speech defects.d. bradykinesia and tremors.

35. With Alzheimer’s disease, the time from diagnosis to death can be as little as

a. seven years.b. 10 years.c. five years.d. three years.

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

a. Trueb. False

37. ______________________ (a 10-minute test to administer) has been shown to be a useful screening tool for detecting mild cognitive impairment (MCI) and detecting MCI in pa-tients who have Alzheimer’s disease, and dementia, and who are at risk for developing dementia.

a. The Montreal Cognitive Assessment (MOCA)b. The Mini-Cog testc. The Clinical Dementia Rating (CDR)d. The ABC test


38. Depression in the elderly can cause many of the cognitive defects that are common to

a. delirium.b. dementia.c. Parkinsonian motor signs.d. normal aging.

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

a. a normal part of aging.b. fit into the diagnostic criteria for dementia.c. in an intermediate state between normal cognitive functioning

and dementia.d. All of the above

40. True or False: It is well established that advanced age it-self is a risk factor for delirium.

a. Trueb. 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 as-sessment 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 testc. the Clinical Dementia Rating (CDR)d. the ABC test

44. The CAM has two parts: the first is an assessment tool that is used to detect cognitive impairment and the second is a short screening test that is used

a. to distinguish delirium from drug usage.b. to distinguish delirium from dementia.c. to identify Parkinsonian motor signs.d. to diagnose Alzheimer’s disease.

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

a. a complete blood test (CBC).b. a urinalysis and urine culture.c. taking the patient’s body temperature.d. neuro-imaging to confirm whether delirium is present.

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

a. Trueb. False

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

a. self-identityb. conditionc. limitationsd. inability to communicate

48. A nurse introduces herself to the patient each time she talks to the patient, points to calendars and clocks fre-


quently in conversation, and talks about current events: this is an example of

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

49. Successful conversation with the patient who has demen-tia 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 neuropsy-chiatric 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 nor-mal for a patient who has dementia and a nurse should ac-cept it as part of the patient experience.

a. Trueb. False

52. A recommended method for identifying and treating neu-ropsychiatric 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 de-tecting the presence of pain in patients who have demen-tia and could also be used to assess the response to pain treatments.


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

BID-2).

54. The drugs most commonly used to treat dementia are

a. antipsychotics.b. cholinesterase inhibitors.c. benzodiazepines.d. All of the above

55. The DICE Method operates with the assumption that neu-ropsychiatric behavior problems in dementia patients are caused by

a. reality disorientation.b. dementia.c. a stressor.d. delirium.

56. When treating dementia, the dose of cholinesterase in-hibitors should be slowly titrated and at the end of ___________ of the maximum dose the patient should be re-assessed.

a. one monthb. eight weeksc. one weekd. six months

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

a. the drug should be stopped.b. drug dosing should be increased.c. drug treatment should be continued until improvement is seen.d. None of the above

58. True or False: The benzodiazepines may seem to be a logi-cal choice for treating behavioral problems associated with dementia, but they should not be routinely used in these clinical situations.

a. Trueb. False


CORRECT ANSWERS:

1. One of the defining characteristics of dementia is a. inability to perform activities of daily living.


b. Alzheimer’s disease and vascular pathologies.


b. attention deficits and confusion.


a. acute.


c. drugs and dementia.

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

b. False

7. The onset of neurologic changes of dementia are usually

b. slow and progressive.

8. Use physical restraints with patients who have dementia

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

9. Neuropsychiatric behavior problems in patients who have dementia

a. are caused by an external or internal stimulus.


10. The use of antipsychotics for treating patients who have dementia

d. is questionably effective and potentially dangerous.

11. The drug most commonly used to treat agitation in pa-tients who have delirium is

b. haloperidol.

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

b. False

13. Benzodiazepines are

c. seldom useful and may worsen dementia or delirium.


d. Rivastigmine.


a. Memantine.

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

c. can have many different causes.

17. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) has replaced the term dementia with the term

a. major/mild cognitive disorder.

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

b. With major or mild cognitive disorder


19. Dementia can be usefully divided into two categories:

d. reversible and irreversible.

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

a. True

21. Which of the following is NOT able to cause irreversible de-mentia?

d. None of the above

22. In most cases, dementia caused by _______________ is re-versible but not always.

c. a drug

23. Drugs that can cause dementia and delirium include:

d. All of the above

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

a. lesions

25. Frontotemporal lobe dementia is a neurodegenerative dis-ease caused by _____________ the frontal and temporal lobe.

b. atrophy of

26. ____________________ is a chronic, progressive neurodegenera-tive disease that is characterized by the presence of ab-normal deposits of protein that accumulate in neurons in specific areas of the brain.


27. Patients who have dementia often suffer from neuropsy-chiatric problems such as

c. agitation.


28. True or False: In dementia patients, there is typically no disturbance of consciousness: the patient is awake, alert, and responsive.

a. True

29. In Alzheimer’s disease, lesions in the parietal and tempo-ral lobes

d. All of the above

30. When making the diagnosis of ____________ it must be speci-fied if it is hyperactive, hypoactive, or involves a mixed level of activity.

d. delirium

31. ___________ is an acute change in mental status character-ized by confusion and disturbances in cognition.

d. Delirium

32. Parkinson’s disease’s characteristic motor symptoms are similarly found with __________________ patients.


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

c. visual hallucinations.

34. The hallmark signs of frontotemporal dementia are

c. behavioral and speech defects.

35. With Alzheimer’s disease, the time from diagnosis to death can be as little as

d. three years.

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

a. True


37. ______________________ (a 10-minute test to administer) has been shown to be a useful screening tool for detecting mild cognitive impairment (MCI) and detecting MCI in pa-tients who have Alzheimer’s disease, and dementia, and who are at risk for developing dementia.

a. The Montreal Cognitive Assessment (MOCA)

38. Depression in the elderly can cause many of the cognitive defects that are common to

b. dementia.

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

c. in an intermediate state between normal cognitive function-ing and dementia.

40. True or False: It is well established that advanced age it-self is a risk factor for delirium.

b. False

41. In many cases, delirium is

d. a clinical diagnosis.

42. When delirium is suspected, the first step of a patient as-sessment includes

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

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

a. the Confusion Assessment Method (CAM).

44. The CAM has two parts: the first is an assessment tool that is used to detect cognitive impairment and the second is a short screening test that is used

b. to distinguish delirium from dementia.


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

c. taking the patient’s body temperature.

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

a. True

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

a. self-identity

48. A nurse introduces herself to the patient each time she talks to the patient, points to calendars and clocks fre-quently in conversation, and talks about current events: this is an example of

d. reality orientation.

49. Successful conversation with the patient who has demen-tia involves

d. All of the above

50. It is recommended that dementia patients with neuropsy-chiatric behavior problems be treated

c. first using behavioral and environmental approaches.

51. True or False: Neuropsychiatric behavior problems are nor-mal for a patient who has dementia and a nurse should ac-cept it as part of the patient experience.

b. False

52. A recommended method for identifying and treating neu-ropsychiatric behavior problems in dementia patients is known as


a. the DICE Method.

53. The ____________________________________ is very reliable for de-tecting the presence of pain in patients who have demen-tia and could also be used to assess the response to pain treatments.

d. Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2).

54. The drugs most commonly used to treat dementia are

b. cholinesterase inhibitors.

55. The DICE Method operates with the assumption that neu-ropsychiatric behavior problems in dementia patients are caused by

c. a stressor.

56. When treating dementia, the dose of cholinesterase in-hibitors should be slowly titrated and at the end of ___________ of the maximum dose the patient should be re-assessed.

b. eight weeks

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

a. the drug should be stopped.

58. True or False: The benzodiazepines may seem to be a logi-cal choice for treating behavioral problems associated with dementia, but they should not be routinely used in these clinical situations.

a. True


References Section

The reference section of in-text citations include published works in-tended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text.

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