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Delerium and Dementia Sadly, I Still Have Nothing New to Disclose Since Early This Week John Engstrom, M.D

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Delerium and Dementia Sadly, I Still Have Nothing New to Disclose Since Early This Week John Engstrom, M.D Disclosures Delerium and Dementia Sadly, I still have nothing new to disclose since early this week John Engstrom, M.D. Professor of Neurology Using the ARS for this talk August 2018 MOCA reproduced at end of slides 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, comprehend • If history suggests a cognitive problem, • Memory-Recall of 3 common objects at 5 then a methodical mental status exam minutes; if misses an answer give a prompt is necessary • Abstractions-Similarities and differences (e.g.-apple vs. orange; lake vs. river) 1 Q1: Which part of an abnormal mental status exam negates testing for memory? Screen Attention First A. Abstractions • Attention-requires input of numbers, immed 33% B. Attention span 28% recall, and verbal output of numbers – Everyone must remember a numerical sequence C. Orientation 22% 17% – Exceptions: deafness, ESL, no education D. Visual fields • Memory-input of objects, hold memory of objects for five minutes, then verbal recall • Screen attention first (or after orientation) s n s n o ld io ti ie ct ta f a n al tr e u s ri is b O V A Attention span 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 • Evidence that the delirium is caused by a information, react to inputs, and result in “metabolic” disorder expressive or motor outputs in response 2 Delerium-Practical Clinical Features History• provided by family, friends, or co- workers who know the patient well – Establish pre-morbid mental baseline – Review medications and “substances” Initial• test– Review of choice medical if comorbidities often to call or interview someone who knows history Q2: Which neuro exam finding helps distinguish delerium from dementia? .Fine,A. postural tremor .AsterixisB. .MyoclonusC. Delerium-Clinical Accompaniments .FocalD. neurol findings Fluctuation• over minutes-hours-lethargy or .AllE. of the above hyperactivity based on many observations (hemiparesis) Vital• signs – Tachycardia/hypersympathetic state-infection, substance use, substance withdrawal – New hypertension/hypotension Meningismus-Resistance• – Fever-risk of infection to neck flexion Exam• features above normal in dementia 73% 6% 8% Fine, postural tremor 4% Asterixis 8% Myoclonus Focal neurol findings ... Neurologic exam findings that help distinguish delerium from dementia All of the above Fine• postural tremor-Acute/subacute onset- often sign of hypersympathetic state Asterixis-Loss• of tone with wrist extension – Classic with renal or hepatic failure Myoclonus-sudden• – Seen in many metabolicdischarge conditions of motor cells producing an asymmetric jerk-metabolic 3 Delerium-Metabolic Causes/Evaluation-I Delerium-Metab Causes/Evaluation-II Metabolic Causes Laboratory Studies Metabolic Causes Laboratory Studies Hypo/hypernatremia Na Substance use/withdrawal Toxicology screen Renal failure BUN, Cr Alcohol intox/withdrawal Alcohol level 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, UA intermittent seizures are not obvious Meningitis Lumbar puncture (LP), – Get more history from observers re poss sz Cultures, CBC, CXR, UA Neurologic Causes – Patient has pre-existing brain dz (e.g.-stroke) Subarachnoid hemorrhage Head CT, LP • The patient is malnourished and has Cerebral infarction Head CT or MRI thiamine deficiency (e.g.-Wernicke’s) Seizures, post-ictal state Consider head CT/MRI, EEG • Neuro exam in uncooperative patient? 4 Neuro Exam for Focality in the Delerium Cranial• Nerve Examination -Facial asymmetry(Uncooperative) on command or with Patient grimace Brainstem• reflexes-Lower 2/3 face-upper motor neuron -Entire face-facial nerve or brainstem – Pupils-midbrain: asymmetric, reactive? – Corneals-pons: asymmetric, reactive? – Breathing/pulse-medulla: normal/abnormal More Pitfalls in the Outpatient Delerium• dx as Assessment of Delerium somnolence or reduced responsiveness – Use vitals, gen exam, neurologic signs as above Neuro Exam for Focality in the An• undiagnosed– EEG nl depression, neurodegenerative diffusely slow disease in delerium Delerium (Uncooperative) Patient is already present (e.g.-AD) depression Motor-grade• best strength; note asymmetry – Slower recovery from delerium/post-ictal state – Moves arms/legs symmetrically vs. gravity? – Establish baseline mental function – Able to stand with/without assistance? in setting of – Able to walk with/without assistance – If unable to stand/walk-due to focal weakness, Sensory-Symmetry• focal sensory of loss, withdrawal or focal leg of imbalance arms or legs to pain stimulus of equal intensity Q3: What is Not Routinely Useful in Managing Improving Delerium after A. Use of anti-psychotic to control B. Use ofbehavior prescribed eyewearHospital Discharge C. Use of prescribed hearing aids D. Frequent reorientation of the patient in E. Encouragea familiar falling environment asleep on a schedule 92% Use of anti-psychotic to ... 1% Use of prescribed eyewear 2% 4% Use of prescribed hearing... 2% Frequent reorientation o... Encourage falling asleep .. 5 Non-Pharmacologic Prevention Delerium-Conclusions and Management of Delerium • Especially at hospital discharge to home • If the patient can give a completely coherent • Frequent reorientation of the patient history, then the mental status examination • Using eyeglasses and hearing aids is almost always normal • Early PT/mobiliz-restore baseline function • Initial assessment of suspected delerium should include: • Sleep hygiene – Establish pre-morbid mental baseline – Prevent daytime naps – Rev medication or substance use and disuse – Encourage falling asleep on a schedule – Review medical comorbidities Delerium-Conclusions • 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–a• decline in cognition interfering with daily function and independence – No disturbance of consciousness Impairment• – Best assessedin at least as anone outpatient cognitive domain:Dementia – Memory and learning – Language – Executive function-judgment, planning, reasoning – Social cognition, perceptual-motor function Approach to Patient/Family: Visit One Best• history from pt and family or sig other General/neuro• exams and limited lab testing May• need separate input from others if patient is defensive or argumentative Patients• often lack insight into the problem Goals of Dementia Assessment – Denial or excuses-remembering something is Establish• the presence/absence of dementia not important anymore or too old for an activity Understand• areas of cognitive impairment – Social and interpersonal skills preserved early and the severity of the impairment Understand• the functional consequences of areas of cognitive impairment/preservation Determine• the likely etiology Q4: Which one of the following is important in a dementia history? A. Recent memory function B. Executive function C. Language D. Assessing impact of cognition on E. All of thesafety above risks 96% 0% Recent memory function 0% Executive function 0% 4% Language Assessing impact of cogn... All of the above 7 Dementia History-Memory Dementia History-Language • Age Associated Memory Challenges • Expressive aphasia-Reduced volume of – Forgetting words or names language but perservation of content words – Slowing of cognitive processing • Paraphasic errors-substituting one word for – Increased difficulty with multitasking another that sounds similar but has a different meaning (e.g.-cow for car) • Worrisome Memory Deficits – Forgetting recent conversations • Neologisms-word sounds that are not words – Forgetting appointments and plans • Receptive aphasia-word salad, nonsensical – Not paying bills on time words, paraphasic errors, neologisms Dementia History-Functional Dementia History-Executive Function Assessment • Performing complex tasks • Basic ADLs preserved until late-bathing, • Initiating plans eating, dressing, grooming, continence • Following multistep directions-using a • Safety risks-driving, climbing stairs, falling remote control or computer or near falls, car accidents, getting lost in • Visuospatial deficits-difficulty using hands familiar surroundings for a complex task or misjudging the • Food preparation, household maintenance position of objects in space • Keeping appointments, managing finances 8 Dementia-Role of Comorbidities Screening Mental Status + Physical/Psychosocial factors? • Attention-Digit span forward (nl > 6-7) • Special senses-Diminished hearing or vision • Orientation-time, place, person
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