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

Disclosures Delerium and Dementia -Sadly, I still have nothing new to disclose since early my last presentation John Engstrom, M.D. -Using the ARS for this talk Professor of Neurology -References include answer key and link to UCSF Memory and Aging web site: April 2019 https://memory.ucsf.edu -MOCA test reproduced at end of slides Mental Status Assessment Screening Mental Status • Attention-Digit span forward first (nl-6-7) • If the patient can give a completely • Orientation-time, place, person coherent history, then the mental status • Language-repetition, naming, comprehend examination is probably normal • Recent 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 (e.g.- is necessary apple vs. orange; lake vs. river) 1

Q1: Which abnormal mental status Screen Attention First exam finding negates the value of testing for recent memory? • Attention-requires input of numbers, immediate recall, and verbal output of 1) Abstractions numbers 2) Attention span – Everyone must remember a numerical sequence 3) Orientation – Exceptions: deafness, ESL, no education 4) Visual fields • Memory-input of objects, hold memory of objects for five minutes , then verbal recall 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 brainstem • Acute or subacute onset RAS (Reticular Activating System) • Other cognitive abnl (e.g.-disorientation) • Bilateral cerebral regions that receive • Not explained by another neurologic dz sensory inputs, process and interpret information, react to inputs, and result in • Evidence that the delirium is caused by a expressive or motor outputs in response “metabolic” disorder 2

Delerium-Clinical Accompaniments Delerium-Practical Clinical Features • Fluctuation over minutes-hours-lethargy or hyperactivity based on many observations • History provided by family, friends, or 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 • Initial test of choice if often to call or • Meningismus-Resistance to neck flexion interview someone who knows history • 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 hand extension 3) Myoclonus – Classic with renal or hepatic failure 4) New focal neurologic findings – Seen in many metabolic conditions (e.g.-hemiparesis) • Myoclonus-sudden discharge of motor cells 5) All of the above producing an asymmetric jerk-metabolic 3

Delerium-Metabolic Causes/Evaluation-I Delerium-Metab Causes/Evaluation-II Metabolic Causes Laboratory Studies Metabolic Causes Laboratory Studies Substance use/withdrawal Toxicology screen Hypo/hypernatremia Na Alcohol intox/withdrawal Alcohol level Renal failure BUN, Cr Medication overuse/withdrawal Review meds; consider drug level Hypoxia, ischemia PO2 Hypercalcemia, Hyper Mg Calcium, magnesium Hypo/hyperglycemia Glucose Hyperphosphatemia Phosphate Hypo/hyperthyroidism, Thyroid function tests Hepatic Failure LFTs; ammonia Delerium – Common Causes and Pitfalls in the Outpatient Evaluation Assessment of Delerium Infectious Causes Laboratory Studies • The delerium is a post-ictal state and the Sepsis Cultures, CBC, Chest X-Ray, intermittent seizures are not obvious UA Meningitis Lumbar puncture (LP), – Get more history from observers re poss sz Cultures, CBC, CXR, UA – Patient has pre-existing brain dz (e.g.-stroke) Neurologic Causes • The patient is malnourished and has Subarachnoid hemorrhage Head CT, LP thiamine deficiency (e.g.-Wernicke’s) Cerebral infarction Head CT or MRI • Neuro exam in uncooperative patient? Seizures, post-ictal state Consider head CT/MRI, EEG 4

Neuro Exam for Focality in the Delerium Neuro Exam for Focality in the (Uncooperative) Patient Delerium (Uncooperative) Patient • Cranial Nerve Examination • Motor-grade best strength; note asymmetry -Facial asymmetry on command or with grimace – Moves arms/legs symmetrically vs. gravity? -Lower 2/3 face-upper motor neuron – Able to stand with/without assistance? -Entire face-facial nerve or brainstem – Able to walk with/without assistance • Brainstem reflexes – If unable to stand/walk-due to focal weakness, – Pupils-midbrain: asymmetric, reactive? focal sensory loss, or focal leg imbalance – Corneals-pons: asymmetric, reactive? • Sensory-Symmetry of withdrawal of arms – Breathing/pulse-medulla: normal/abnormal or legs to pain stimulus of equal intensity Q3: What is Not Routinely Useful in More Pitfalls in the Outpatient Managing Improving Delerium after Assessment of Delerium Hospital Discharge • Delerium dx as depression in setting of 1) Use of anti-psychotic to control behavior somnolence or reduced responsiveness 2) Use of prescribed eyewear – Use vitals, gen exam, neurologic signs as above 3) Use of prescribed hearing aids – EEG nl depression, diffusely slow in delerium 4) Frequent reorientation of the patient in a • An undiagnosed neurodegenerative disease familiar environment is already present (e.g.-AD) 5) Encourage the patient to fall asleep on a – Slower recovery from delerium/post-ictal state schedule – Establish baseline mental function 5

Delerium-Conclusions I Non-Pharmacologic Prevention and Management of Delerium • If the patient can give a completely coherent history, then the mental status examination • Especially at hospital discharge to home is almost always normal • Frequent, calm reorientation of the patient • Initial assessment of suspected delirium: • Using eyeglasses and hearing aids – Establish pre-morbid mental baseline • Early PT/mobiliz-restore baseline function – Rev medication or substance use and disuse • Sleep hygiene – Review medical comorbidities – Prevent daytime naps – Assoc exam signs-fever, inc HR, tremor, stiff – Encourage falling asleep on a schedule neck, myoclonus, asterixis Delerium-Conclusions II • Screen attention first • Have your list of screening labs for delerium at the ready • Beware of outpt traps-baseline depression, neurodegen dz, post-ictal state, thiamine def • Non-pharmacologic measures are proven to enhance mental functioning in delerium pts 6

Dementia Goals of Dementia Assessment • Establish the presence/absence of dementia • Dementia–a decline in cognition interfering with daily function and independence • Understand areas of cognitive impairment – No disturbance of consciousness and the severity of the impairment – Best assessed as an outpatient • Understand the functional consequences of • Impairment in at least one cognitive domain: areas of cognitive impairment/preservation – Memory and learning • Determine the likely etiology – Language – Executive function-judgment, planning, reasoning – Social cognition, perceptual-motor function Approach to Patient/Family: Visit One Q4: Which one of the following is important in a dementia history? • Best history from pt and family or sig other • General/neuro exams and limited lab testing 1) Recent memory function • May need separate input from others if 2) Executive function patient is defensive or argumentative 3) Language • Patients often lack insight into the problem 4) Assessing impact of cognition on safety risks – Denial or excuses-remembering something is 5) All of the above not important anymore or too old for an activity – Social and interpersonal skills preserved early 7

Dementia History-Language Dementia History-Memory • Expressive aphasia-Reduced volume of • Age-Associated Memory Challenges language but perservation of content words – Forgetting words or names • Paraphasic errors-substituting one word for – Slowing of cognitive processing another that sounds similar but has a – Increased difficulty with multitasking different meaning (e.g.-cow for car) • Worrisome Memory Deficits • Neologisms-word sounds that are not words – Forgetting recent conversations • Receptive aphasia-word salad, nonsensical – Forgetting appointments and plans words, paraphasic errors, neologisms – Not paying bills on time Dementia History-Functional Dementia History-Executive Function Assessment • Performing complex tasks • Basic ADLs preserved until late-bathing, eating, dressing, grooming, continence • Initiating plans • Safety risks-driving, climbing stairs, falling • Following multistep directions-using a or near falls, car accidents, getting lost in remote control or computer familiar surroundings • Visuospatial deficits-difficulty using hands • Food preparation, household maintenance for a complex task or misjudging the position of objects in space • Keeping appointments, managing finances 8