1. Who Am I? Where Am I? Facts and Fears About Dementia and Delirium November 12, 2007
Karen Rose, PhD, RN
Dorothy Tullmann, PhD, RN
Assistant Professors of Nursing
University of Virginia

2. Presentation Objectives
Dementia
Focus on long-term aspects of caring for persons with dementia
Emphasize caregiving environment
Delirium
How delirium differs from dementia
Importance of early recognition of delirium

3. What is Dementia
Dementia is a general term for the loss of memory and other intellectual abilities serious enough to interfere with daily life.
Classifications
Alzheimer’s disease (AD): 50% - 70% of all dementias
Vascular dementia
Mixed dementia
Frontotemporal lobe dementia
Lewy Body dementia
Mild cognitive impairment
Others

4. How Common is Dementia? < 65 years Rare 65 – 85 years 10%
Less than 4% of all cases of dementia
65 – 85 years %
At age 65, risk increases 1% per year
86 – 100+ years 50%
At age 86, risk increases 11% per year
The fear of developing dementia is FAR greater!!

5. Alzheimer’s Quiz! Fact or Fiction?
1. Memory loss is a natural part of the aging process.
2. Alzheimer’s is a fatal disease.
3. All relatives of Alzheimer’s patients inherit the disease.
4. Alzheimer’s is a disease of the elderly.
5. Life is over upon receiving an Alzheimer’s diagnosis.

6. U.S. Department of Health and Human Services, 2001
Who Are Caregivers?
Family caregivers are the mainstay of caregiving support to persons with dementia.
Over 30 percent of caregivers for the elderly are, themselves, age 65 years or older.
U.S. Department of Health and Human Services, 2001

7. Living with Alzheimer’s
Audio from Vermont Public Radio, November 6, 2007

8. Benefits of Caregiving
Psychological
Self-worth
Altruism
Connection with care recipient
Economic
Costs of care at home vs. costs of care in institutions
Home care: ≈ $19,000 / year
In California alone, cost of care is 2.1 billion now;
4.6 billion in 2020.
Alzheimer’s Association, 2006; Fox et al., 2001

9. Perils of Caregiving Physical Psychological Increased risks for:
Cardiovascular disease
Metabolic syndrome
Other co-morbidities
Mortality
Psychological
Increased incidence of:
Anxiety
Depressive symptoms
Connell et al., 2001; Gallicchio, 2002; Irwin, 2001; Schulz &
Beech, 1999

10. Caring for the Caregiver
Importance of caring for self
For you
For them
Community resources
One size does not fit all

11. Importance of Caregiving Environment
Socialization (Zarit et al., 2004).
Activities (Rentz et al., 2002; Palo-Bengtsson & Ekman, 2002).
Mental & Physical Stimulation (Camp et al., 1997).
Sleep (Richards, Beck, et al., 2001).

12. When Things Go Bad
Dementia is a PROGRESSIVE loss of memory and function….
When changes are abrupt: Something’s wrong!!

13. What is Delirium? “Semantic muddle” Acute brain syndrome
Acute confusion
Acute confusional states
Acute brain failure
ICU (intensive care unit) psychosis
Sundowner syndrome
Lipowski, 1990

14. Definition of Delirium
Reduced level of consciousness
difficulty focusing, shifting or sustaining attention
Cognitive change
deficit of language, memory, orientation, perception; not attributed to dementia
Develops rapidly (hours to days)
varies during the day
General medical condition has directly caused the condition
American Psychological Association, 2002

15. Variations of Delirium
Hyperactive
Increased responsivity to stimuli; hyperalert
Moves constantly; may be combative
Hypoactive
Quiet and listless; hypoalert
Appears indifferent, oblivious
Mixed
Alternates irregularly
American Psychological Association, 2000

16. How Does Delirium Differ from Dementia?
Rapid onset
Fluctuates; worse at night
Altered level of consciousness
Easily distracted; attention impaired
Dementia
Chronic, insidious
Symptoms progressive but stable
Level of consciousness usually not affected
Tries hard to do task; great effort to recall

17. What Causes Delirium? The pathogenesis of delirium is unclear.
Anatomic defects?
Changes in different parts of the brain seen on diagnostic scans
Neurotransmitter imbalance?
Serotonin, acetylcholine deficit
Dopamine excess
See Trzepacz, 2000 in “Further Reading”
Genetic predisposition?

18. Who is At Risk for Delirium?
Predisposing factors
Age (60+ years)
Brain damage
Chronic brain disease (e.g. Alzheimer’s)
Precipitating factors (organic causes)
Primary cerebral disease
Systemic diseases affective brain (e.g. sepsis)
Drug, poison intoxication (e.g. polypharmacy)
Withdrawal from substances of abuse (especially alcohol and sedative-hypnotics)
Lipowski, 1990; Inouye et al, 1999

19. Facilitating factors Psychosocial stress Sleep deprivation
Sensory underload or overload
Immobilization
Lipowski, 1990; Inouye et al., 1999

20. Ely et al., 2001, 2004; McNicoll et al., 2003
Delirium in ICU
New instrument to screen for delirium in ICU (non-verbal patients)
Higher mortality rate
Long-term cognitive and functional decline
Mechanically ventilated patients
> 80% had at least one day of delirium
Related to intravenous sedation
In ICU patients, 65+ years
31% had delirium on admission to the ICU
31% developed delirium in ICU
Ely et al., 2001, 2004; McNicoll et al., 2003

21. What Can Be Done in the Hospital?
Early recognition
Treat underlying condition
Medication reaction
Infection
Non-pharmacologic management
Medication (antipsychotics, sedatives) should be a last resort.

22. What Can I Do? If you see rapid mental changes, report them.
The changes could signal an undetected illness or other physiologic problem.
Delirium may be prevented or slowed.
Minimize psychosocial stress
Avoid sleep deprivation
Avoid sensory underload or overload
Avoid immobilization
Frequent reorientation

23. Thank you!
Questions?