1. Delirium or Dementia? Dave Garbera F1 Doctor Arrowe Park Hospital

2. Learning Objectives What is the difference between delirium and dementia? Common causes of an acute confusional state Types of dementia Case study

3. Confused Patients Delirium Dementia Psychiatric Third Year

4. Delirium Also known as Acute Confusional State Arises during a number of different acute illnesses Present in up to 20% of hospital admissions “ A temporary mental state with a sudden onset, usually reversible, including symptoms of poor attention, inability to concentrate, disorientation, anxiety and sometimes hallucinations ”

6. A lcohol D rugs E lectrolytes L iver failure I nfection R etention I ntracranial pressure U rea M etabolic disease Delirium Causes

7. Drugs

8. There are LOTS of drugs that are known to precipitate confusion Alcohol Benzodiazepines (e.g. Diazepam, Lorazepam) Opiates (e.g. Morphine, Codeine) Tricyclics (e.g Amitryptiline) Digoxin Lithium

9. Electrolyte Disturbance Any electrolyte imbalance can cause confusion Abnormal values cause cells in the brain to swell Osmosis because cells contain lots of potassium Hyponatraemia Vomiting and diarrhoea Build up of fluid in the body (e.g heart failure) Hypercalcaemia Malignancy Hyperparathyroidism

10. Liver Disease Cirrhosis Alcohol Hepatitis Drugs Carcinoma Primary hepatoma Carcinoma Vascular Ischaemia Infection Hepatitis Epstein-Barr virus Metabolic Wilson’s disease

11. Liver Disease Anything that leads to hepatic failure prevents toxic blood metabolites from being processed in the liver Metabolites then remain in the blood and cause disturbance in the brain

12. Infection Number of acute infections can cause delirium Mechanism unknown, but probably due to inflammatory response disrupting neurotransmitters UTI Pneumonia Sepsis Meningitis and encephalitis Malaria

13. Retention One of the most common causes of confusion in hospital Both urinary and faecal Unknown aetiology Multiple studies Nobody knows why this should cause confusion Hypothesised that faeces become impacted due to constipation, which presses on bladder

14. Intracranial Pressure Brain metastases Space occupying lesions Increase pressure in cranium Damage to brain tissue Increased volume in brain Oedema Hydrocephalus Trauma Space occupying haematoma Direct damage to brain tissue

15. Urea Often arises from renal failure Chronic kidney disease Acute renal failure Nephrotoxic drugs Urea and other waste products normally excreted by the kidneys remain in the blood Acute confusional state caused by build up of toxins in the brain, disrupting neurotransmission

16. Metabolic Disease Vitamin deficiency Especially B1 and B12 Involved in nerve conduction Hypoxia (respiratory disease) Lack of oxygen Brain is not well perfused Thyroid disease Levels of thyroxine linked to precipitating confusion

17. Presentation Acute onset Fluctuating course Impaired consciousness Impaired cognition Disorientation Poor attention Agitation Sleep cycle disturbed Hallucinations

18. History Usual medical history Any recent illness? Good medication history Obtain a collateral history from relatives or friends The patient will probably not be very cooperative!

19. Examination A B C Conscious level Vitals O 2 Sats BP Pulse Temperature ENT, respiratory, cardiovascular, abdominal exams Check for lymphadenopathy and constipation Mini mental state exam

21. Investigations Blood glucose ABC-DEFG Bloods FBC U&E LFT TFT Vitamin B12 Calcium Cardiac enzymes ABG Urine dipstick Blood cultures ECG Chest / abdo x-ray CT Brain (Lumbar puncture)

22. Management Treat underlying cause Constipation – laxatives Urinary retention – catheterise Infection – antibiotics Electrolytes – fluids, slow calcium production Stop drugs suspected of causing confusion Replace with others if possible Measure cognitive function regularly Mini mental state examination

23. Management Supportive Clock, calendar in room Familiar objects from home Staff consistency Involve family and carers Helpful in stopping patients wandering Medical treatment Antipsychotic medication - haloperidol Haloperidol is for scared patients Other antipsychotics for other hallucinations or delusions e.g quetiapine

24. Delirium Acute illness Sudden onset Altered consciousness Hallucinations Fluctuating disorientation and memory loss Thorough history and examination Treat underlying cause and stop precipitating drugs DRUGSCONSTIPATIONINFECTION

25. Dementia Alzheimer’s Disease Vascular Dementia Lewy Body Dementia Fronto-temporal Dementia “ A progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal aging ”

26. Alzheimer’s Disease Most common type of dementia Accounts for up to 60% of all cases More common in women Risk increases with age Approx. 25-33% of 85 year olds in the West Some evidence of hereditary link Up to 10% more likely to develop Alzheimer’s if a first degree relative has it

27. Key Features Memory impairment Ability to learn new information Recall previously learned facts Cognitive disturbances Agnosia – inability to recognise people or objects Apraxia – difficulty with sequencing Language disturbance Higher functioning such as planning

28. Key Features Personality well preserved No fluctuation in symptoms STEADY decline No problems with loss of consciousness No hallucinations or behavioural problems until very late in the illness Sleep-wake cycle often reversed Eventually loss of central functions e.g continence

29. Alzheimer’s Disease Course Time Severity Gradual decline over many years

30. Pathology Due to deposition of abnormal proteins throughout the brain Beta-amyloid plaques These cause destruction of neurones and therefore cognitive decline Neurofibrillary tangles Deposits of protein known as Tau which become ‘tangled’ causing neurone loss

32. Vascular Dementia Associated with other vascular problems Ischaemic Heart Disease TIA or stroke Smoking Similar features to Alzheimer’s Characteristic ‘stepwise’ pattern of decline

33. Vascular Dementia Course Time Severity ‘Stepwise’ decline Abrupt decline in cognition with each event Vascular event

34. Dementia with Lewy Bodies Very similar in pathology to Alzheimer’s Additional protein deposits in the brain stem known as Lewy Bodies Similar course Additional features of: Parkinsonism Hallucinations from the outset (usually disturbing)

35. Fronto-temporal Dementia Also known as Pick’s Disease Tau deposition similar to Alzheimer’s General cognitive decline Additional features of: Personality change Disinhibition Inappropriate actions

37. History Very important – has the decline been sudden or steady? Like delirium, it is important to take a collateral history from a friend or relative The patient will probably be unable to tell you accurately themselves Rule out all causes of delirium before diagnosing dementia Acute illness? Medication? Constipation?

38. Investigations Diagnosis is usually clinical and based on the history given by friends, family or carers Mini mental state examination A score of 23 or less indicates probable dementia Standard battery of investigations for delirium CT Brain if unsure Generalised cerebral atrophy Enlargement of ventricles

39. Treatment Very few treatment options No cure Most promising currently are anti-acetylcholinesterase inhibitors Donepezil Rivastigmine Theory that lack of neurones, and therefore acetylcholine, slows cognition These drugs prevent reuptake of acetylcholine in the synapse, therefore maximizing cognitive function Unclear as to how much these drugs slow decline

40. Alzheimer’s Disease Course Time Severity Gradual decline over many years

41. Support Support for patient, family and carers is very important Visits from specialist nurse Incontinence control Counselling Keep family informed as to what the course of the illness will be and what to expect There is no effective treatment

42. Delirium or Dementia? DeliriumDementia OnsetSuddenGradual DurationAcuteChronic CauseAcute illnessBrain disorder CourseOften reversibleProgressive DisorientationEarlyLate StabilityVariableMostly stable ConsciousnessAltered earlyVery late Attention SpanOften reducedSlightly reduced HallucinationsCommonUncommon MemoryVariableLost Need for treatmentUrgentDesirable

43. Case Study 75 year old male presents with marked memory loss, difficulty recognising family. No loss of consciousness or hallucinations. His daughter lives in New Zealand and is able to visit once a year. He complains of burning pain on urination for four days PMH Lung cancer Liver metastases CKD Stage IV

44. Medication and Family History Atenolol Digoxin Simvastatin Aspirin Omeprazole Father had Alzheimer’s disease

45. Examination Temperature 38.2 º C Pulse 100 BP 130/80 Respiratory rate 14 O 2 Sats 99% on room air Mini mental state exam - 23 Chest clear

46. Differential Diagnosis? Delirium Possible UTI Several risk factors in PMH Medication Fever Dementia Family history Sustained inability to recognise people No hallucinations Mental state not fluctuating

47. Investigations Blood glucose 6.5 Bloods Hb 130 WCC 24 CRP 150 LFT Normal TFT Normal U&E Normal Calcium normal Digoxin level normal Arterial Blood Gases PaO 2 14kPa PaCO 2 5kPa Blood cultures No significant growth ECG Sinus rhythm No abnormality

48. Investigations Urine dipstick Nitrates +++ Leukocytes +++ Blood + Microscopy confirms E.Coli

52. Diagnosis? Delirium secondary to urinary tract infection 5 day course of ciprofloxacin to treat Patient returns four weeks later with daughter She says he is still confused Burning sensation has disappeared

53. What next? CT Brain

55. Diagnosis? Alzheimer’s disease Many elderly patients will have multiple risk factors for developing an acute confusional state Start on anti-acetylcholinesterase inhibitor Donepezil Advice and support to family

56. Remember Make sure you rule out all other causes before jumping to conclusions Not all elderly people presenting with confusion will have dementia Not everyone presenting with UTI and confusion will be delirious

57. Any Questions? Thank you!