Dr. Chr is t ine Tomkinson, BSc BMBSAdul t Neuro logy Res ident ,
McMaster Univers i tyOntar io , Canada
Confusion in the Older Adult
76 yr old woman with confusion…
Focused Medical History Duration? Constant or fluctuating? ROS – fever, malaise, cough,
dysuria, recent trauma
76 yr old woman with confusion…
Past Medical History Previous similar episodes? Known dementia diagnosis?
If so, what’s different today?
76 yr old woman with confusion…
Medications List of medications; any recent changes? Who controls meds and how are they given (blister
pack, etc) Any concerns with med administration? Look at meds – more/less than expected?
76 yr old woman with confusion…
Social History Who lives with her? Recently widowed? Social outlets? Diet, alcohol use
Delirium
Disturbance in consciousness, with reduced ability to focus, sustain, or shift attention
Change in cognition or development of a perceptual disturbance
Disturbance develops over short period of time (hrs to days)
Fluctuates during course of dayCaused by a medical condition, substance
intoxication or medication side effect
Why do we care?
10-15% prevalence in general medical/surgical in patients
Approx 30% of older patients during a hospital stay
60-70% in ICU80-90% palliative care
Increased length of hospital stay, institutional discharge, mortality
Clinical Features
D – Disordered thinkingE – Euphoria, Emotions (fearful, depressed,
angry)L – Language impaired (dysarthia, dysnomia)I – Illusions, delusions, hallucinationsR – Reversal of sleep-wake cyclesI – Inattention/Distractible U – Unaware and disorientedM – Memory deficits
Causes of Delirium - DIMS
Drugs New medications, Interactions Overdose/Withdrawal Side effects **Anticholingerics Poisons
Causes of Delirium - DIMS
Infectious/Inflammatory Sepsis Meningitis/Encephalitis UTI/Pneumonia/Cellulitis
Causes of Delirium - DIMS
Metabolic Electrolyte disturbance Hyper/Hypo-glycemia Hypercarbia Hypoxemia Endocrine – Thyroid, Parathyroid, Pituitary, Adrenal Systemic organ failure – Liver/Renal Nutritional – Wernicke’s (Thiamine), B12, Folate
Causes of Delirium - DIMS
Structural Head injury – SAH, SDH Stroke, Seizure Space occupying lesion – Neoplasm, Abscess
Risk Factors
Predisposing Factors Precipitating Factors
Underlying brain diseases (dementias)
Polypharmacy
Advanced age Infection
Sensory impairment Dehydration
Immobility
Malnutrition
Catheter use
Hospitalization/Nursing home
Dementia
Development of multiple cognitive deficits Memory impairment At least one of:
Aphasia Apraxia Agnosia Disturbance in executive function
Gradual onset and progressive decline
Epidemiology
Estimated 35.6 million people worldwide (2010)
Total projected to double every 20 years In Middle East and North African countries, projected
increase of 125%
Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization report. Alzheimers Res Ther, 2012. 4(5)
Epidemiology
Approx 15% over age 65Incidence doubles every 10 years after 6050% prevalence over age 90Prevalence increased in Down Syndrome and
head injury (AD)
Types of Dementia
Alzheimer’s Disease – 60-80%
STM loss (anterograde amnesia) Loss of visuospatial skills, insight, executive
functioning, apraxia Vascular Dementia (multi-infarct) – 10-20%
Abrupt onset and stepwise deterioration Focal findings/Deficits specific to area affected May have vascular risk factors or stroke history
Mixed
Types of Dementia
Frontotemporal Dementia – 10%
Disinhibition, socially inappropriate Emotional lability Progressive expressive aphasia Memory preserved
Lewy Body Dementia – 15-25%
Fluctuating cognition/attention with progressive decline
Visual hallucinations Parkinsonism
Parkinson’s related Dementia
Reversible Dementia
Normal Pressure hydrocephalusVitamin deficiencies
Wernicke-Korsakoff’s (Thiamine – EtOH) B12, Folate
MedicationsThyroid dysfunctionHypo/Hyper-glycemiaCortisolDepressionHeavy metals
So what should you check?
Collateral history from family memberVital signs
Temperature Glucose SpO2
GEMS Diamond
Management of a Confused Adult
Well-lit, quiet roomGet down to the patient’s levelHearing aids/GlassesReverse stethoscope if neededTalk slowly, clearly and use plain language
Management of a Confused Adult
Give them time to process questionsOrient and re-orient; use family membersAvoid restraints, catheters, linesStop unnecessary medsTreat underlying causes
References
Atia M, Rastin T, and Scott C. Neurology. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc., Toronto 2011. p.10-15.
VIHA. CAM v3 Delirium in the older person: a medical emergency. www.viha.ca/mhas/resources/delirium/ (Accessed June 30,2014)
Francis J and Young GB. Diagnosis of delirium and confusional states. In: UpToDate, Wilterdink JL (Ed), UpToDate, Waltham, MA. (Accessed June 26, 2014).
Harrington, C.J. and K. Vardi, Delirium: presentation, epidemiology, and diagnostic evaluation (part 1). R I Med J (2013), 2014. 97(6): p. 18-23.
Hake AM and Farlow MR. Clinical features and diagnosis of dementia with Lewy bodies. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed July 1, 2014).
Holiff J, White M, and Wilson KR. Psychiatry. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc, Toronto 2011. p.17-19.
Shadien MF and Larson EB. Risk factors for cognitive decline and dementia. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed June 30,2014).
World Health Organization. Dementia: A public health priority. WHO Press, Geneva 2012.
Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization report. Alzheimers Res Ther, 2012. 4(5): p. 40.
Wright CB. Etiology, clinical manifestations, and diagnosis of vascular dementia. In: UpToDate, Eichler AF (Ed), UpToDate, Waltham, MA (Accessed July 1, 2014).