IM Dementia, Delirium and Depression

Normal aging

• Etiology:
  • -no consistent, progressive deviations on memory testing
    
• Management:
  • -reminders work: notes, visual tips
    
  • -absence of significant effects on ADLs

Mild cognitive impairment

• Etiology:
  • -typically younger
    
  • -memory problem w/o deficits in other domains
    
  • -no functional impairment
    
  • -only 10-12% per year progress to dementia

Dementia

• Etiology:
  • acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient
    
  • -progressive & disabling
    
  • -not an inherent aspect of aging
    
  • -different from normal cognitive lapses
• Epidemiology:
  • -Risk factors: age, family hx, head injury, female, fewer years of education
    
  • -1 in 10 persons > 65 y/o, nearly half of persons > 85 y/o have Alzheimer’s
    
  • -Life expectancy of 8-10 years after symptoms begin
• Path:
  • -mutations of chromosomes 1, 14, 21 (Down syndrome)= rare early-onset [before age 60] familial forms of dementia
    
  • -apolipoprotein E4 (APOE*4 allele) on chromosome 19= increased risk & decreased onset of age
• Diagnostic:
  • -serologic tests for TSH & vitamin B12 level, LFTs, blood chemistries
    
  • -consider imaging when sx have occurred for < 2 years, neuro signs are asymmetric or focal, onset occurs at age < 65 y/o, clinical
  • the picture suggests normal-pressure hydrocephalus, pt. has had recent fall or head trauma
• Non-pharmacologic treatment of dementia:
  • -Cognitive enhancement (e.g. crossword puzzles), Individual/group therapy, Regular appointments, Environmental modification, Attention to safety
• Pharmacologic treatment of dementia:
  • Cholinesterase inhibitors (donepezil, rivastigmine, galantamine); memantine; other cognitive enhancers, antidepressants, psychoactive meds
• Treating psychoses in dementia:
  • -antipsychotic meds: black box warning for elderly dying sooner (start low, go slow)

Vascular (multi-infarct)dementia

• Etiology:
  • -sudden onset, progresses stepwise with further ischemia
    
  • -symptoms depend on the area of ischemia
    
  • -focal neurologic symptoms & signs OR evidence of cerebrovascular disease
    
  • -deficits in the absence of delirium
    
  • -impaired memory AND aphasia, apraxia, agnosis, disturbed executive function

Alzheimer’s disease

• Etiology:
  • gradual onset progresses over 8-10 years on avg.
    
  • -memory impairment, apraxia later on
    
  • -impaired memory AND aphasia, apraxia, agnosis, disturbed executive function
    
  • -significantly impaired social, occupational function
    
  • -not due to CNS or other physical conditions, or an Axis I disorder

Lewy body dementia

• Etiology:
  • -gradual onset, gradual progression (quicker than Alzheimer’s)
    
  • -memory, visuospatial symptoms, hallucinations (often children playing) early on, fluctuations
    
  • -Parkinsonism (AFTER memory loss)

Fronto-temporal dementia

• Etiology:
  • -gradual onset, usually < age 60; gradual progression (quicker than Alzheimer’s)
    
  • -disinhibition, apathy, behavior changes; no motor symptoms
    
  • -imaging: atrophy in frontal and temporal lobes

Delirium

• Etiology:
  • acute onset, cognitive fluctuations over hours or days, impaired consciousness & attention
• Epidemiology:
  • -10x increased risk of death in hospital
  • -3-5x increased risk of nosocomial infections, prolonged stay, nursing-home placement
  • -increased risk of death up to 2 years following discharge
  • -predisposing factors: advanced age, dementia, functional impairment in ADLs, medical comorbidity, hx of alcohol abuse, male, decreased vision or hearing
• DSM-IV diagnosis of delirium:
  • -Disturbance of consciousness w/ reduced ability to focus, sustain, or shift attention
  • -Change in cognition (eg, memory deficit, disorientation, language disturbance) or a perceptual disturbance not better accounted for by existing dementia
  • -Development over a short time (hours to days) and fluctuation during the day
  • -Evidence from history, physical, or labs that the disturbance is a direct physiologic consequence of a medical condition or a drug
• Types:
  • -hyperactive or agitated: 25% of all cases
    
  • -Mixed
    
  • -Hypoactive: > 50% of all cases, but less recognized and appropriately treated
    
  • -Additional features include emotional lability, psychosis, hallucinations (scary)
• Risk Factors for postoperative delirium:
  • -cognitive impairment
    
  • -age
    
  • -physical functional impairment
    
  • -hx of alcohol abuse
    
  • -abnormal serum chemistries
    
  • -intrathoracic and aortic aneurysm surgery
• Evaluation for postoperative delirium:
  • -based on H&P: CBC, electrolytes, renal function tests, LFTs, urinalysis, serum drug levels, ABGs, CXR, EKG, cultures
    
  • -cerebral imaging helpful w/ head trauma or new focal neurologic findings
    
  • -EEG & LP helpful w/ associated seizure activity or signs of meningitis
• DDX:
  • HE STOPS for TIPS AEIOU
    
  • Hepatic/HTN; E-lytes (Na and Ca)
    
  • Stroke Trauma, Opiates, Psych, Seizures
    
  • Temp, Infxn, Porphyria, Sepsis
    
  • Acidosis, Endocrine, Intoxication, O2/CO2, Uremia
• Meds to minimize or eliminate in delirium:
  • -alcohol
    
  • -anticholinergics
    
  • -anticonvulsants
    
  • -antidepressants (anticholinergic only)
    
  • -antihistamines (anticholinergic only)
    
  • -antiparkinsonian agents
    
  • -antipsychotics
    
  • -benzos
    
  • -chloral hydrate
    
  • -H2-blocking agents
    
  • -analgesics (esp. meperidine)
• Only reversible cause of dementia:
  • depression

Depression

• Etiology:
  • -decreased motivation during cognitive testing
    
  • -maintain language & motor skills
    
  • -effective tx of depressive symptoms may improve cognition
• Epidemiology:
  • -minor depression common: 15% of older persons
    
  • -major depression not common: 1-2% (elders less likely to recognize or endorse depressed mood)
    
  • -bipolar disorders: incidence declines with age
• Diagnostic differences for depression in older adults:
  • -more often report somatic symptoms
    
  • -less often report depressed mood, guilty
    
  • -may present with the preoccupation of physical concerns
• Older adults & suicide:
  • -increased risk
    
  • -1/4 of all suicide occurs in persons > 65 y/o
    
  • -risk factors: depression, physical illness, living alone, male gender, alcoholism
    
  • -violent methods more common
• Treatment of depression in older adults:
  • -continuation: for 6 mos. to prevent a relapse
  • -maintenance: for 3 yrs or longer to prevent future recurrence
  • -combine psychotherapy w/ antidepressant
  • -SSRIs first line:
    • 40% respond to drugs within 6 weeks,
    • additional 15-25% respond with continued treatment for 6 weeks
  • -ECT:
    • one of the best treatments for those > 60 y/o
    • (first-line for high suicide risk, the standard for psychotic depression)

Bereavement

• Etiology:
  • -most disturbing symptoms resolve in 2 months
    
  • -not associated with marked functional impairment