64
Dementia and Delirium
Janice Smolowitz
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Caregiving Functional Ability
Cognition Safety
Family Dynamics
LEARNING OUTCOMES
1. Define dementia and delirium. 6. Discuss the clinical manifestations, diagnostic studies,
2. Classify the different etiologies of dementia. and nursing and interprofessional care for a patient with
3. Explain the pathophysiology for different types of dementia. Alzheimer disease.
4. Discuss the clinical manifestations of mild cognitive 7. Explain the etiology, pathophysiology, clinical
impairment. manifestations, diagnostic studies, and nursing and
5. Describe the clinical manifestations, diagnostic studies, interprofessional care for a patient with delirium.
and nursing and interprofessional care for a patient with
dementia.
KEY TERMS
Alzheimer disease (AD) mild cognitive impairment (MCI)
delirium mixed dementia
dementia retrogenesis
dementia with Lewy bodies (DLB), Table 64.3 sundowning
frontotemporal lobar degeneration (FTLD), Table 64.3
This chapter discusses dementia and delirium, with a focus on be marked intellectual decline. Table 64.1 compares key features
the nursing management of patients with Alzheimer disease of dementia, delirium, and depression. Your ability to interview
(AD). Cognitive impairment refers to any deficit in intellectual the patient and family members about presenting symptoms
functioning, including problems with memory, orientation, and signs can help with early diagnosis and treatment.
attention, and concentration. The consequences of cognitive
impairment can be devastating for the person and caregivers.
Dementia adversely affects functional ability and the person’s
DEMENTIA
ability to work, fulfill responsibilities, and perform activities Dementia is a disorder characterized by a decline from the pre-
of daily living (ADL). There is a high risk for many problems, vious level of function in 1 or more cognitive domains: complex
including injury, impaired nutrition, and social isolation. attention, executive function, language, learning and memory,
Persons with dementia and delirium may have symptoms perceptual-motor, and social cognition.1,2 The cognitive decline
of depression. Depression and dementia are often mistaken for interferes with the ability to function and perform daily activ-
one another, especially among older adults. Manifestations of ities. This decline does not occur with the onset of acute con-
depression, especially among older adults, may include sadness, fusion, such as delirium, or the onset of another major mental
difficulty concentrating, fatigue, apathy, feelings of despair, and problem, such as depression.
inactivity. When depression is severe, poor concentration and The number of patients diagnosed with dementia is increas-
inattention may result, causing memory and functional impair- ing. AD is the most common form of dementia.3 It accounts for
ment. When dementia and depression occur together, there can 60% to 80% of all cases of dementia (Fig. 64.1).
1573
,1574 SECTION 12 Problems Related to Movement and Coordination
TABLE 64.1 Comparison of Dementia, Delirium, and Depression
Feature Dementia Delirium Depression
Onset Subtle, gradual Abrupt, although initially can be subtle Often coincides with life changes. Often
abrupt
Progression Slow Abrupt. Can fluctuate from day to day Variable, rapid to slow but may be uneven
Duration Years (average of 8, can be longer) Hours to days to weeks. Can be prolonged Can be several months to years, especially
if not treated
Thinking Difficulty with abstract thinking, impaired Disorganized, distorted. Slow or accelerated Intact but with apathy, fatigue. May
judgment, words difficult to find incoherent speech be indecisive. Feels a sense of
hopelessness. May not want to live
Perception Misperceptions often present. Delusions and Distorted. Delusions and hallucinations May deny or be unaware of depression.
hallucinations May have feelings of guilt
Psychomotor May pace or be hyperactive. As disease Variable. Can be hyperactive or hypoactive, or Often withdrawn and hypoactive
behavior progresses, may not be able to perform tasks or mixed
movements when asked
Sleep-wake Sleeps during the day. Frequent awakenings at Disturbed sleep. Reversed sleep-wake cycle Disturbed, often with early morning
cycle night. Fragmented sleep awakening
Dementia with Normal pressure hydrocephalus is a rare disorder char-
Lewy bodies acterized by an obstruction in the flow of cerebrospinal fluid
~10% Vascular dementia (CSF). This causes a buildup of CSF in the brain. Manifestations
~20% include dementia, urinary incontinence, and difficulty walking.
Meningitis, encephalitis, or head injury may cause the con-
dition. If diagnosed early, it is treatable by surgery in which a
Other types shunt is inserted to divert the fluid away from the brain.
• Frontotemporal
lobar degeneration
• Parkinson’s
Clinical Manifestations
Alzheimer disease disease The onset of manifestations varies depending on the cause.
60%-80% • Normal pressure Manifestations of neurologic degeneration usually occur grad-
hydrocephalus
• Creutzfeldt-Jakob ually and progress over time. Symptoms of VaD may appear
disease abruptly or progress in a stepwise pattern. While the cause of
Fig. 64.1 Causes of dementia. dementia cannot be determined based only on the history of
symptom progression, patterns can guide your thinking about
the cause. An acute change that occurs over days to weeks or
Etiology and Pathophysiology subacute change that occurs over weeks to months may indicate
Dementia is caused by treatable and untreatable conditions. an infectious or metabolic cause of dementia, such as enceph-
Table 64.2 describes types of dementia and their underlying alitis, meningitis, hypothyroidism, or drug-related dementia.
causes. Treatable causes may initially be reversible. However, Other manifestations of dementia are discussed in the section
irreversible changes can occur with prolonged exposure or on clinical manifestations of AD.
disease.
The most common causes are neurodegenerative conditions Diagnostic Studies
that cannot be reversed (Table 64.3). Most of these are due to The diagnosis is focused on determining the cause (e.g., revers-
AD.4 Other causes include dementia with Lewy bodies (DLB), ible versus irreversible). An important first step is a thorough
frontotemporal dementia (FTD), and Parkinson disease with medical, neurologic, and psychologic history. During the his-
dementia (PDD). Vascular or multi-infarct dementia (VaD) is a tory, give special attention to the cognitive and behavior changes
loss of cognitive function caused by vascular disease. VaD may that have occurred. Family members and significant others can
be caused by a single infarct (stroke) or multiple strokes.5 It is give important information. Obtain information about (1)
more common in men. Subcortical dementia is the most com- problems with judgment; (2) reduced interest in hobbies/activ-
mon type of VaD. It occurs when small vessels deep in the brain ities; (3) repeating questions, stories, or statements; (4) trouble
develop thick walls and become stiff. This reduces blood flow, learning how to use a tool or appliance; (5) forgetting the month
which damages the nerve fibers that carry signals to white mat- or year; (6) problems handling financial affairs; (7) difficulty
ter. This process can cause infarcts near the base of the brain.6 remembering appointments; and (8) consistent problems with
Mixed dementia occurs when 2 or more types of dementia thinking and/or memory.
are present at the same time. It is characterized by the hallmark Obtain information about diet and nutrition, alcohol use,
abnormalities of AD and another type of dementia. Usually, the and medications. Include herbal supplements and recreational
other type of dementia is VaD, but it can be other types. substances in the medication history. Ask about drugs that can
, CHAPTER 64 Dementia and Delirium 1575
TABLE 64.2 Causes of Dementia other possible conditions. Routine screening tests include
electrolyte panel, liver function tests, serum vitamin B12 level,
Type of Dementia Cause
complete blood count (CBC), and thyroid function tests.3–5
Neurodegenerative • AD Specialized laboratory tests, such as red blood cell folate in a
disorders • Amyotrophic lateral sclerosis (ALS)
patient with alcohol use disorder or ionized serum calcium in
• Dementia with Lewy bodies (DLB)
a patient with multiple myeloma, are ordered based on history.
• Down syndrome
• Frontotemporal lobar degeneration (FTLD)
Head CT or MRI may show strokes, tumors, and other changes.
• Huntington disease Positron emission tomography (PET) can examine brain activ-
• Parkinson disease ity. In some instances, genetic testing may be considered based
Vascular diseases • Chronic subdural hematomaa on family history.
• Subarachnoid hemorrhagea
• Vascular (multi-infarct) dementia Interprofessional and Nursing Care
Immunologic diseases • AIDS If there is an identifiable cause, treatment is aimed at treat-
or infections • Encephalitisa ing that cause. Other management measures are similar to
• Infections (e.g., Creutzfeldt-Jakob disease) the care of patients with AD (described later in this chapter).
• Meningitisa
Preventive measures for VaD include treating risk factors,
• Multiple sclerosis
such as hypertension, diabetes, smoking, hypercholesterol-
• Neurosyphilisa
• Systemic exertion intolerance disease
emia, and dysrhythmias. Stroke is discussed in Chapter 62.
• Systemic lupus erythematosusa Drugs given to patients with AD are also useful for patients
Medicationsb • Anticholinergics with VaD.
• Antiparkinsonian drugs
• Cardiac drugs: digoxin, methyldopa
• Cocaine
ALZHEIMER DISEASE
• Heroin Alzheimer disease (AD) is a chronic, progressive, irreversible
• Hypnotics neurodegenerative brain disease. It most often affects persons
• Opioids age 65 and older. More than 6.2 million people are currently
• phenytoin (Dilantin)
living with AD in the United States.3 It is thought that by 2050,
• Tranquilizers
this number will increase to 12.7 million people.3 AD is the 6th
Metabolic or nutrition • Alcohol use disorder
diseases • Cobalamin (vitamin B12) deficiencya
leading cause of death in the United States. It is the 5th-leading
• Folate deficiencya cause of death among persons age 65 and older.
• Hyperthyroidisma Only a small number of people younger than 60 years of age
• Hypothyroidisma develop AD. When AD develops in someone younger than 60
• Thiamine (vitamin B1) deficiencya years, it is called early-onset AD. AD that occurs in people over
Systemic diseases • Dialysis dementiaa 60 years old is called late-onset AD.
• Hepatic encephalopathya AD progresses slowly. It has a long preclinical phase, which
• Uremic encephalopathya may last up to 20 years. The average clinical duration is 4 to 8
• Wilson disease years. Some patients have lived for 20 years after diagnosis.
Trauma • Head injurya
The burden of caring for a patient with AD is well docu-
Tumors • Brain tumors (primary)a
mented. In 2020, family members and friends provided $257
• Metastatic tumorsa
Ventricular disorders • Hydrocephalusa billion of informal (unpaid) care for persons with AD.3 This
estimate includes 15.3 billion hours of assistance. Reasons for
aPotentially reversible.
bThese
providing informal care include wanting the person to remain
are examples of drugs that may cause cognitive impairment
at home (65%), being able to stay close to the person (48%), and
that is potentially reversible.
feeling obligated to provide care (38%). Many informal caregiv-
ers are women. More than 60% of caregivers are married and
impair cognition, such as analgesics, anticholinergics, psycho- living with a partner or are in a long-term relationship. 30% of
tropics, and sedative-hypnotics. caregivers are age 65 or older. 64% of informal caregivers report
The physical assessment is done to assess for other poten- that caregiving is stressful (Box 64.1). Nearly 92% say it is also
tial medical conditions. For example, slow movement, rigidity, rewarding.4,5
asymmetric tremor of an extremity, and shuffling gait suggest
Parkinsonism. Dementia, urinary incontinence, and ataxic gait Etiology
suggest normal pressure hydrocephalus. The neurologic assess- We do not know the exact cause of AD.7,8 It is likely a combina-
ment includes a mental status examination or screening test. tion of multiple factors (Box 64.2).
Agreement among findings from the assessment, screening
tests, and history help confirm the presence of dementia. Aging
Based on the history and physical assessment, diagnostic The greatest risk factor for AD is age. Most people with AD are
studies are ordered to confirm the most likely cause and exclude diagnosed at age 65 or older. While age is the greatest risk factor,
Dementia and Delirium
Janice Smolowitz
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Caregiving Functional Ability
Cognition Safety
Family Dynamics
LEARNING OUTCOMES
1. Define dementia and delirium. 6. Discuss the clinical manifestations, diagnostic studies,
2. Classify the different etiologies of dementia. and nursing and interprofessional care for a patient with
3. Explain the pathophysiology for different types of dementia. Alzheimer disease.
4. Discuss the clinical manifestations of mild cognitive 7. Explain the etiology, pathophysiology, clinical
impairment. manifestations, diagnostic studies, and nursing and
5. Describe the clinical manifestations, diagnostic studies, interprofessional care for a patient with delirium.
and nursing and interprofessional care for a patient with
dementia.
KEY TERMS
Alzheimer disease (AD) mild cognitive impairment (MCI)
delirium mixed dementia
dementia retrogenesis
dementia with Lewy bodies (DLB), Table 64.3 sundowning
frontotemporal lobar degeneration (FTLD), Table 64.3
This chapter discusses dementia and delirium, with a focus on be marked intellectual decline. Table 64.1 compares key features
the nursing management of patients with Alzheimer disease of dementia, delirium, and depression. Your ability to interview
(AD). Cognitive impairment refers to any deficit in intellectual the patient and family members about presenting symptoms
functioning, including problems with memory, orientation, and signs can help with early diagnosis and treatment.
attention, and concentration. The consequences of cognitive
impairment can be devastating for the person and caregivers.
Dementia adversely affects functional ability and the person’s
DEMENTIA
ability to work, fulfill responsibilities, and perform activities Dementia is a disorder characterized by a decline from the pre-
of daily living (ADL). There is a high risk for many problems, vious level of function in 1 or more cognitive domains: complex
including injury, impaired nutrition, and social isolation. attention, executive function, language, learning and memory,
Persons with dementia and delirium may have symptoms perceptual-motor, and social cognition.1,2 The cognitive decline
of depression. Depression and dementia are often mistaken for interferes with the ability to function and perform daily activ-
one another, especially among older adults. Manifestations of ities. This decline does not occur with the onset of acute con-
depression, especially among older adults, may include sadness, fusion, such as delirium, or the onset of another major mental
difficulty concentrating, fatigue, apathy, feelings of despair, and problem, such as depression.
inactivity. When depression is severe, poor concentration and The number of patients diagnosed with dementia is increas-
inattention may result, causing memory and functional impair- ing. AD is the most common form of dementia.3 It accounts for
ment. When dementia and depression occur together, there can 60% to 80% of all cases of dementia (Fig. 64.1).
1573
,1574 SECTION 12 Problems Related to Movement and Coordination
TABLE 64.1 Comparison of Dementia, Delirium, and Depression
Feature Dementia Delirium Depression
Onset Subtle, gradual Abrupt, although initially can be subtle Often coincides with life changes. Often
abrupt
Progression Slow Abrupt. Can fluctuate from day to day Variable, rapid to slow but may be uneven
Duration Years (average of 8, can be longer) Hours to days to weeks. Can be prolonged Can be several months to years, especially
if not treated
Thinking Difficulty with abstract thinking, impaired Disorganized, distorted. Slow or accelerated Intact but with apathy, fatigue. May
judgment, words difficult to find incoherent speech be indecisive. Feels a sense of
hopelessness. May not want to live
Perception Misperceptions often present. Delusions and Distorted. Delusions and hallucinations May deny or be unaware of depression.
hallucinations May have feelings of guilt
Psychomotor May pace or be hyperactive. As disease Variable. Can be hyperactive or hypoactive, or Often withdrawn and hypoactive
behavior progresses, may not be able to perform tasks or mixed
movements when asked
Sleep-wake Sleeps during the day. Frequent awakenings at Disturbed sleep. Reversed sleep-wake cycle Disturbed, often with early morning
cycle night. Fragmented sleep awakening
Dementia with Normal pressure hydrocephalus is a rare disorder char-
Lewy bodies acterized by an obstruction in the flow of cerebrospinal fluid
~10% Vascular dementia (CSF). This causes a buildup of CSF in the brain. Manifestations
~20% include dementia, urinary incontinence, and difficulty walking.
Meningitis, encephalitis, or head injury may cause the con-
dition. If diagnosed early, it is treatable by surgery in which a
Other types shunt is inserted to divert the fluid away from the brain.
• Frontotemporal
lobar degeneration
• Parkinson’s
Clinical Manifestations
Alzheimer disease disease The onset of manifestations varies depending on the cause.
60%-80% • Normal pressure Manifestations of neurologic degeneration usually occur grad-
hydrocephalus
• Creutzfeldt-Jakob ually and progress over time. Symptoms of VaD may appear
disease abruptly or progress in a stepwise pattern. While the cause of
Fig. 64.1 Causes of dementia. dementia cannot be determined based only on the history of
symptom progression, patterns can guide your thinking about
the cause. An acute change that occurs over days to weeks or
Etiology and Pathophysiology subacute change that occurs over weeks to months may indicate
Dementia is caused by treatable and untreatable conditions. an infectious or metabolic cause of dementia, such as enceph-
Table 64.2 describes types of dementia and their underlying alitis, meningitis, hypothyroidism, or drug-related dementia.
causes. Treatable causes may initially be reversible. However, Other manifestations of dementia are discussed in the section
irreversible changes can occur with prolonged exposure or on clinical manifestations of AD.
disease.
The most common causes are neurodegenerative conditions Diagnostic Studies
that cannot be reversed (Table 64.3). Most of these are due to The diagnosis is focused on determining the cause (e.g., revers-
AD.4 Other causes include dementia with Lewy bodies (DLB), ible versus irreversible). An important first step is a thorough
frontotemporal dementia (FTD), and Parkinson disease with medical, neurologic, and psychologic history. During the his-
dementia (PDD). Vascular or multi-infarct dementia (VaD) is a tory, give special attention to the cognitive and behavior changes
loss of cognitive function caused by vascular disease. VaD may that have occurred. Family members and significant others can
be caused by a single infarct (stroke) or multiple strokes.5 It is give important information. Obtain information about (1)
more common in men. Subcortical dementia is the most com- problems with judgment; (2) reduced interest in hobbies/activ-
mon type of VaD. It occurs when small vessels deep in the brain ities; (3) repeating questions, stories, or statements; (4) trouble
develop thick walls and become stiff. This reduces blood flow, learning how to use a tool or appliance; (5) forgetting the month
which damages the nerve fibers that carry signals to white mat- or year; (6) problems handling financial affairs; (7) difficulty
ter. This process can cause infarcts near the base of the brain.6 remembering appointments; and (8) consistent problems with
Mixed dementia occurs when 2 or more types of dementia thinking and/or memory.
are present at the same time. It is characterized by the hallmark Obtain information about diet and nutrition, alcohol use,
abnormalities of AD and another type of dementia. Usually, the and medications. Include herbal supplements and recreational
other type of dementia is VaD, but it can be other types. substances in the medication history. Ask about drugs that can
, CHAPTER 64 Dementia and Delirium 1575
TABLE 64.2 Causes of Dementia other possible conditions. Routine screening tests include
electrolyte panel, liver function tests, serum vitamin B12 level,
Type of Dementia Cause
complete blood count (CBC), and thyroid function tests.3–5
Neurodegenerative • AD Specialized laboratory tests, such as red blood cell folate in a
disorders • Amyotrophic lateral sclerosis (ALS)
patient with alcohol use disorder or ionized serum calcium in
• Dementia with Lewy bodies (DLB)
a patient with multiple myeloma, are ordered based on history.
• Down syndrome
• Frontotemporal lobar degeneration (FTLD)
Head CT or MRI may show strokes, tumors, and other changes.
• Huntington disease Positron emission tomography (PET) can examine brain activ-
• Parkinson disease ity. In some instances, genetic testing may be considered based
Vascular diseases • Chronic subdural hematomaa on family history.
• Subarachnoid hemorrhagea
• Vascular (multi-infarct) dementia Interprofessional and Nursing Care
Immunologic diseases • AIDS If there is an identifiable cause, treatment is aimed at treat-
or infections • Encephalitisa ing that cause. Other management measures are similar to
• Infections (e.g., Creutzfeldt-Jakob disease) the care of patients with AD (described later in this chapter).
• Meningitisa
Preventive measures for VaD include treating risk factors,
• Multiple sclerosis
such as hypertension, diabetes, smoking, hypercholesterol-
• Neurosyphilisa
• Systemic exertion intolerance disease
emia, and dysrhythmias. Stroke is discussed in Chapter 62.
• Systemic lupus erythematosusa Drugs given to patients with AD are also useful for patients
Medicationsb • Anticholinergics with VaD.
• Antiparkinsonian drugs
• Cardiac drugs: digoxin, methyldopa
• Cocaine
ALZHEIMER DISEASE
• Heroin Alzheimer disease (AD) is a chronic, progressive, irreversible
• Hypnotics neurodegenerative brain disease. It most often affects persons
• Opioids age 65 and older. More than 6.2 million people are currently
• phenytoin (Dilantin)
living with AD in the United States.3 It is thought that by 2050,
• Tranquilizers
this number will increase to 12.7 million people.3 AD is the 6th
Metabolic or nutrition • Alcohol use disorder
diseases • Cobalamin (vitamin B12) deficiencya
leading cause of death in the United States. It is the 5th-leading
• Folate deficiencya cause of death among persons age 65 and older.
• Hyperthyroidisma Only a small number of people younger than 60 years of age
• Hypothyroidisma develop AD. When AD develops in someone younger than 60
• Thiamine (vitamin B1) deficiencya years, it is called early-onset AD. AD that occurs in people over
Systemic diseases • Dialysis dementiaa 60 years old is called late-onset AD.
• Hepatic encephalopathya AD progresses slowly. It has a long preclinical phase, which
• Uremic encephalopathya may last up to 20 years. The average clinical duration is 4 to 8
• Wilson disease years. Some patients have lived for 20 years after diagnosis.
Trauma • Head injurya
The burden of caring for a patient with AD is well docu-
Tumors • Brain tumors (primary)a
mented. In 2020, family members and friends provided $257
• Metastatic tumorsa
Ventricular disorders • Hydrocephalusa billion of informal (unpaid) care for persons with AD.3 This
estimate includes 15.3 billion hours of assistance. Reasons for
aPotentially reversible.
bThese
providing informal care include wanting the person to remain
are examples of drugs that may cause cognitive impairment
at home (65%), being able to stay close to the person (48%), and
that is potentially reversible.
feeling obligated to provide care (38%). Many informal caregiv-
ers are women. More than 60% of caregivers are married and
impair cognition, such as analgesics, anticholinergics, psycho- living with a partner or are in a long-term relationship. 30% of
tropics, and sedative-hypnotics. caregivers are age 65 or older. 64% of informal caregivers report
The physical assessment is done to assess for other poten- that caregiving is stressful (Box 64.1). Nearly 92% say it is also
tial medical conditions. For example, slow movement, rigidity, rewarding.4,5
asymmetric tremor of an extremity, and shuffling gait suggest
Parkinsonism. Dementia, urinary incontinence, and ataxic gait Etiology
suggest normal pressure hydrocephalus. The neurologic assess- We do not know the exact cause of AD.7,8 It is likely a combina-
ment includes a mental status examination or screening test. tion of multiple factors (Box 64.2).
Agreement among findings from the assessment, screening
tests, and history help confirm the presence of dementia. Aging
Based on the history and physical assessment, diagnostic The greatest risk factor for AD is age. Most people with AD are
studies are ordered to confirm the most likely cause and exclude diagnosed at age 65 or older. While age is the greatest risk factor,
