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Evaluation and Management of Delirium and Dementia

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Dementia is an illness defined by the presence of progressive irreversible multiple cognitive deficits which interfere with the individuals day to day activities, marked by a decline in functioning, characterized by a change in personality behavior Evaluation and Management of Delirium and Dementia Dr.M.Ashfaq Burney Outline • Definitions • Epidemiology • Delirium assessment, diagnosis, management • Dementia assessment, diagnosis and management Objectives • To be able to identify patients suffering from delirium • To be able to identify patients having dementia • Each of the group management and referral criteria • What are normal memory lapses? Memory in daily task: Unexplained Memory in daily task:Forgetting confusion in familiar places an acquaintance Performance of familiar name task: Forgetting Performance tasks:Leaving food to burn to serveofmeal after preparing Language:Trouble finding the words right word Language: Forgetting simple or Orientation:Forgetting the day or date appropriate words Judgment:Choosing to wear a light sweater Orientation: Getting lost in own on a cold night neighborhood Abstract thinking:Making a mistake in Judgment: Wearing two blouses at one balancingtime cheque book Temporarily misplacing car keys or basic glasses Abstract thinking: Inability to Gradual perceptible change in personality calculation and Putting mood iron in freezer Misplacing objects: Initiative:Occassional tiredness and wrist watch in bowlfrom doing house work Severe and social obligation Personality: Moods swings Initiative: Sustained lack of interest Alzheimer asscociation, what are warning signs?sept.1998 Alzheimer association, what are warning signs?sept.1998 CASE • Dr X was a 74-year-old retired professor, recently diagnosed with Alzheimer's disease He had been started a trial of acetyl cholinesterase inhibitor and had shown a promising early response An elective orthopedic procedure was planned Care was taken to optimize his medical status ahead of time The operation proceeded uneventfully and eighteen hours postoperatively he was doing very well He was discharged home in stable condition In the early hours of the morning following discharge, he suddenly became confused and called out He was taken to the near by clinic, where he was given mg of haloperidol and sent home In the view of the family who were caring for him the drug was found ineffective, as his confusion and agitation worsened So he was taken to your clinic the same day in night Examination showed an extremely agitated, restless man in considerable psychological distress He was in physical restraint, not recognizing his wife • What's going on? • What would be your response? • Dr X was a 74-year-old retired professor, recently diagnosed with Alzheimer's disease He had been started in an open-label trial of acetyl cholinesterase inhibitor and had shown a promising early response An DeliriumCare was taken to optimize elective orthopedic procedure was planned Refer his medical status ahead of time The operation proceeded uneventfully CAM and eighteen hours postoperatively heDo was doing very well He was discharged home in stable condition Do In MMSE the early hours of the morning following discharge, he suddenly became confused and called out He Stop all the medication was taken to the near by clinic, where he was given done mg of haloperidol Get medical investigations In the view of the family who were caring for him the drug was found ineffective, as his confusion and agitation worsened So he was taken to your clinic the same day in night Examination showed an extremely agitated, restless man in considerable psychologic distress He was in physical restraint and not recognizing his Hyponatermia was found to be the cause Foot Note wife • • Later was discharged Other than difficulty with stairs and the bathtub, he was He had continued to be treated symptomatically without addressing the What'sunderlying going on?causes ofindependently mobile nowith assistance in delirium, he may well and haverequired ended up a permanently What would beworsened your response? of medical daily living cognitive statusactivities and more complications Definition of Delirium (Acute Confusional State) Delirium is characterized by • Disturbance of consciousness • Change in cognition that develops over a short period of time The disorder has a tendency to fluctuate during the course of the day There is evidence from the history, examination or investigations that delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication Cognitive Impairment • Is a broad term to describe a wide variety of impaired brain function relating to the ability of a person to: • Think clinical syndrome with deficits in • Concentrate memory or other cognitive abilities that have minimal impact • React to emotions on day-to-day functioning and • Formulate ideas does not meet criteria for dementia • Problem solve • Reason • Remember Differential diagnosis of Cognitive Alzheimer’s disease Impairment • • • • • • • Neurodegenerative Metabolic / Deficiency Vascular (e.g Stroke) Infectious Structural Epileptiform Other Diffuse lewy body disease Dementia of Parkinson's disease Progressive supra-nuclear palsy Fronto-temporal dementia Vitamin B12 deficiency Thyroid disease Alcohol related Neurosyphilis HIV related Herpes simplex encephalitis Creutzfeldt Jacob disease Brain tumor and NPH Complex epilepticus Depression, delirium, trauma, metal toxicity, MS 10 Delirium is common among Delirium Stats older adults in acute care  settings (prevalence Overall prevalence of delirium in the community is only to estimates typically percent, the prevalence increases with age, rising to 14range from 10–60%) percent among those more than 85 years old  Delirium at admission: 14-24%, during hospital stay 6% to 65%, post operatively 15% to 53%  54% Delirious Elderly Patients NOT Recognized By Physicians And Nurses  60% of patients in nursing homes or post acute care setting  The one-year mortality rate associated with cases of delirium is 35 to 40% 11 ... epilepticus Depression, delirium, trauma, metal toxicity, MS 10 Delirium is common among Delirium Stats older adults in acute care  settings (prevalence Overall prevalence of delirium in the community... The one-year mortality rate associated with cases of delirium is 35 to 40% 11 SIGNS OF DELIRIUM • • • • • • • • Disordered thinking Causes of delirium Euphoria, fearful, depressed, angry D- DRUGS... Definitions • Epidemiology • Delirium assessment, diagnosis, management • Dementia assessment, diagnosis and management Objectives • To be able to identify patients suffering from delirium • To be able
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