Delerium and Dementia Sadly, I have nothing to disclose John - PDF document

Disclosures Delerium and Dementia Sadly, I have nothing to disclose John Engstrom, M.D. Professor of Neurology April 2017 Mental Status Assessment Screening Mental Status • If the patient can give a completely • Orientation-time, place, person coherent history, then the mental status • Attention-Digit span forward (nl > 6-7) examination is probably normal • Language-repetition, naming, comprehension • Memory-Recall of 3 common objects at 5 • If history suggests a cognitive problem, minutes; if misses an answer give a prompt then a methodical mental status exam • Abstractions-Similarities and differences is necessary (e.g.-apple vs. orange; lake vs. river) 1

Q1: Which part of an abnormal mental Screen Attention First status exam negates testing for memory? 1) Abstractions • Attention-requires input of numbers and immediate recall 2) Attention span – Everyone must remember a numerical sequence 3) Orientation – Exceptions: deafness, ESL, no education 4) Visual fields • Memory-input of numbers, hold memory of numbers for five minutes , and then recall • Screen attention first (or after orientation) Pathological Basis of Delerium: Delerium-Defining Features Impaired Attention • Inattention-malfunction cerebrum/brainstem • Poor attention-Digit span forward < 6-7 • Arousal and attention centers in the • Subacute onset brainstem (RAS) • Other cognitive abnl (e.g.-disorientation) • Bilateral cerebral regions that receive • Not explained by another neurologic dz sensory inputs, process and interpret information, and react to inputs • Evidence that the delirium is caused by a “metabolic” disorder – Diffuse circuit network (white matter) – Integration centers (gray matter) 2

Delerium-Clinical Accompaniments Delerium-Practical Clinical Features • Fluctuation over minutes-hours-lethargy or hyperactivity based on many observations • History provided by family, friends, co- • Vital signs workers who know the patient well – Tachycardia/hypersympathetic state-infection, – Establish pre-morbid mental baseline substance use, substance withdrawal – Review medications and “substances” – New hypertension/hypotension – Review medical comorbidities – Fever-risk of infection • Call/interview someone who knows history • Meningismus-Resistance to neck flexion • Exam features above normal in dementia Q2: Which neuro exam finding helps Neurologic exam findings that help distinguish delerium from dementia? distinguish delerium from dementia 1) Fine, postural tremor • Fine postural tremor-Acute/subacute onset- often sign of hypersympathetic state 2) Asterixis • Asterixis-Loss of tone with wrist extension 3) Myoclonus – Classic with renal or hepatic failure 4) Focal neurol findings (hemiparesis) – Seen in many metabolic conditions 5) All of the above • Myoclonus-sudden discharge of motor cells producing an asymmetric jerk-metabolic 3

Delerium – Common Causes and Delerium-Metabolic Causes/Evaluation Evaluation Infectious Causes Laboratory Studies Metabolic Causes Laboratory Studies Hyponatremia, hypernatremia Na Sepsis Cultures, CBC, Chest X-Ray, UA Renal failure BUN, Cr Hypoxia, ischemia PO2 Meningitis Lumbar puncture (LP), Hypoglycemia, hyperglycemia Glucose Cultures, CBC, CXR, UA Hypothyroidism, hyperthyroidism Thyroid function tests Neurologic Causes Substance use/withdrawal Toxicology screen Subarachnoid hemorrhage Head CT, LP Alcohol intoxication/withdrawal Alcohol level Medication overuse or withdrawal Review medications; consider drug level Cerebral infarction Head CT or MRI Hypercalcemia, hypermagnesemia Calcium, magnesium Seizures, post-ictal state Consider head CT/MRI, EEG Hyperphosphatemia Phosphate Hepatic Failure LFTs; ammonia Neuro Exam for Focality in the Delerium Pitfalls in the Outpatient (Uncooperative) Patient Assessment of Delerium • Cranial Nerve Examination • The delerium is a post-ictal state and the -Facial asymmetry on command or with grimace intermittent seizures are not obvious -Lower 2/3 face-upper motor neuron – Get more history from observers re poss sz -Entire face-facial nerve or brainstem – Patient has pre-existing brain dz (e.g.-stroke) • Brainstem reflexes • The patient is malnourished and has – Pupils-midbrain: asymmetric, reactive? thiamine deficiency (e.g.-Wernicke’s) – Corneals-pons: asymmetric, reactive • No neuro exam-uncooperative patient – Breathing/pulse-medulla: normal/abnormal 4

Neuro Exam for Focality in the More Pitfalls in the Outpatient Delerium (Uncooperative) Patient Assessment of Delerium • Motor-grade best strength; note asymmetry • Delerium dx as depression in setting of somnolence or reduced responsiveness – Moves arms/legs symmetrically vs. gravity? – Able to stand with/without assistance? – Use somatic neurologic signs as above – EEG nl depression, diffusely slow in delerium – Able to walk with/without assistance – If unable to stand/walk-due to focal weakness, • An undiagnosed neurodegenerative disease focal sensory loss, or focal leg imbalance is present (e.g.-Alzheimer’s dz) • Sensory-Symmetry of withdrawal of arms – Slower recovery from delerium/post-ictal state or legs to pain stimulus of equal intensity – Establish baseline mental function Q3: What is Not Routinely Useful in Non-Pharmacologic Prevention Managing Improving Delerium after and Management of Delerium Hospital Discharge • Especially at hospital discharge 1) Use of anti-psychotic to control behavior • Frequent reorientation of the patient 2) Use of prescribed eyewear • Using eyeglasses and hearing aids 3) Use of prescribed hearing aids 4) Frequent reorientation of the patient in a • Early PT/mobilization familiar environment • Sleep hygiene 5) Encourage falling asleep on a schedule – Prevent daytime naps – Encourage falling asleep on a schedule 5

Delerium-Conclusions Pharmacologic Management of Delerium • Melatonin for sleep-plausible, safe, • If the patient can give a completely coherent unproven history, then the mental status examination is almost always normal • Available clinical data do not support the routine use of anti-psychotics for prevention • Initial assessment of suspected delerium or treatment of delerium should include: – Establish pre-morbid mental baseline – Rev medication or substance use and disuse – Review medical comorbidities Delerium-Conclusions • Distinguishing delerium from dementia depends on the results of the general exam, especially vital signs, and the presence or absence of focal signs on neurologic exam • Non-pharmacologic measures are proven to enhance mental functioning in delerium pts 6

Dementia vs. Delerium: A Family Perspective Dementia • Dementia-“lights are on but nobody home” • Dementia–a decline in cognition interfering with – Patients preserve social graces until late daily function and independence – Mental baseline not normal once probed – No disturbance of consciousness – Recent memory/abstract thinking impaired – Best assessed as an outpatient consistently with little fluctuation • Impairment in at least one cognitive domain: • Delerium-“lights are flickering on and off” – Memory and learning – Attention span is impaired and fluctuates – Language – Risks: medical illness, drugs or substances, – Executive function-judgment, planning, reasoning medical comorbidities, normal mental baseline – Social cognition, perceptual –motor function Approach to Patient/Family: Visit One Goals of Dementia Assessment • Best history from patient and family/friend • Establish the presence/absence of dementia • General/neuro exams plus limited testing • Understand areas of cognitive impairment • May need separate input from others if and the severity of the impairment patient is defensive or argumentative • Understand the functional consequences of • Patients often lack insight into the problem the areas of cognitive impairment – Denial or excuses-remembering something is • Determine the likely etiology not important anymore or too old for an activity – Social and interpersonal skills preserved early 7

Q4: Which one of the following is Dementia History-Memory important in a dementia history? • Age Associated Memory Challenges – Forgetting words or names 1) Recent memory function – Slowing of cognitive processing 2) Executive function – Increased difficulty with multitasking 3) Language • Worrisome Memory Deficits 4) Assessing impact of cognition on safety risks – Forgetting recent conversations 5) All of the above – Forgetting appts and plans – Not paying bills on time Dementia History-Language Dementia History-Executive Function • Reduced volume of language but with • Performing complex tasks perservation of content words • Initiating plans • Paraphasic errors-substituting one word for • Following multistep directions-using a another that sounds similar but has a remote control or computer different meaning (e.g.-cow for car) • Visuospatial deficits-difficulty using hands • Neologisms-sounds that are not words for a complex task or misjudging the position of objects in space 8