1. Canning Division Dementia or Delirium or Depression Dr Nick Bretland Canning Division of General Practice

2. Canning Division What is Dementia? Sustained reduction of previously established mental abilities Involves several areas of cognition Clear consciousness Causes functional problems

3. Canning Division Types of Dementia Alzheimer’s Dementia Vascular Dementia Frontal Lobe Dementia Lewy Body Dementia

4. Canning Division Alzheimer’s Dementia Slowly Progressive Earliest Loss is Recent Memory Often preceded by Depression Progressive decline in intellect Progressive loss of functional abilities Neurological losses

5. Canning Division

6. Vascular Dementia Multi-infarct (usually embolic) Small vessel infarct (disconnects frontal lobes) Picks off individual executive functions Often combined with Alzheimer’s Dementia Neurological symptoms

7. Canning Division Periventricular White Matter Loss

8. Canning Division Frontal Lobe Dementia Specific loss of Frontal Lobe tissue Main losses –Recent Memory –Language –Executive function –Personality change Behaviour Depression Hallucinations –Neurological Symptoms

9. Canning Division Frontal Lobe Atrophy

10. Canning Division Lewy Body Dementia Variable levels of cognitive loss from day to day Parkinsonian features –Tremor –Shuffling Gait –Instability Prominent hallucinations –Well formed –Often people –Not frightening

11. Canning Division Symptoms of Depression Depressed Mood Loss of interest or pleasure Significant appetite or weight loss or gain Poor sleep or excess sleep Psychomotor retardation or agitation Fatigue or loss of energy Feeling worthless or guilt Poor thinking and concentration Suicidal thoughts

12. Canning Division Delirium Transient Global Disorder of Co g nition Affects 20-40% hospital admissions Occurs in 80% of terminal illness Mortality 10-26% Prolongs Hospital Stay by 7 days 25-50% have underlying dementia

13. Canning Division DSM IV Criteria Disturbed Consciousness –Reduced clarity of awareness of environment –Reduced ability to focus or shift attention Change in Cognition –Memory deficit –Language or perceptual disturbance Development over a short period of time and fluctuates through the day History, Examination and Laboratory findings indicate direct physiological consequences of a medical condition

14. Canning Division Subtypes of Delirium 1.Hyperactive Picking at bedclothes Tapping fingers, Agitation 2.Hypoactive Lying passive in bed ( O sign) 3.Mixed 4.Prodromal

15. Canning Division Causes of Delirium INFECTION Hypoxia Hypoglycaemia Hyperthermia Drugs (esp anticholinergics) Withdrawal (alcohol and sedatives) PAIN Metabolic Vitamin deficiency Urinary retention Constipation Sensory deprivation Heart, liver, renal failure

16. Canning Division On the Ward Top risk factors –Pre-existing Cognitive Impairment –Severe Medical Illness –Age 70 or over –Visual Impairment –Depression –Abnormal Sodium levels –Indwewlling Catheter –Use of Physical Restraints –Medications: Pethidine, BZD, Alcohol withdrawal

17. Canning Division Warning Signs! High Index of Suspicion Sudden onset of abnormal behaviour is more likely to be delirium than dementia Hallucinations are more likely to be due to delirium than psychiatric illness Sleep/Wake Cycle Reversal Beware the Hypoactive Patient Multiple medicines Indwelling Catheters Avoid physical restraints Treat it as a medical presentation

18. Canning Division Prevention Environmental –Lighting appropriate to time of day –Single Room –Quiet –Clock and Calender –Family and Carer involvement –Familiar objects in Room Clinical –Assist with Eating and drinking –Glasses and hearing aids –Avoid Constipation –Mobilise –Medication Review –Manage Pain –Promote sleep

19. Canning Division Management Identify Cause –History –Examination –Investigations Rating Scales –Clock Face –CAM –Delirium Rating Scale

20. Canning Division Clockface Test

21. Canning Division Treatment Non-Pharmacological –Same as delirium prevention –One on One nursing –Validation and reality orientation –Family members to assist –Same staff –Relaxation Strategies to help sleep –NO PHYSICAL RESTRAINTS

22. Canning Division Treatment Medical –Treat underlying cause Pharmacological –SEVERE BEHAVIOURAL DISTURBANCE ONLY –Antipsychotic meds (Haloperidol) –Second Generation Antipsychotics (Zyprexa, Risperidone etc) –Low dose –Titrate up and review regularly

23. Canning Division Best Practice On Admission: –Baseline cognitive function (MMSE or AMT) Repeat assessment –day 6 and week 6 –High risk cases may need daily assessment –sudden change in behaviour or cognition If Delirium Suspected –(MMSE declines by 2 or more points) –Formal assessment with diagnostic tool –Refer to “delirium expert”

24. Canning Division Is It Delerium? DeleriumDementiaDepression OnsetAcuteInsidiousVariable CourseFluctuatingSteadily Progressive Diurnal Variation Consciousness & Orientation Clouded & disorientated Clear until late stages Generally unimpaired Attention & Memory Poor short term memory. Inattention Poor short term memory. No Inattention Memory intact Poor attention Psychosis Common (fleeting ideas with simple content) Less commonUncommon (complex ideas with congruent mood)

25. Canning Division http://www.health.gov.au/internet/wcms/publishing. nsf/Content/9E46460CFDAFBA03CA25732B004C 4331/$File/Prevention.pdf http://www.health.gov.au/internet/wcms/publishing. nsf/Content/ageing-delirium.htm~ageing- delirium05.htm