NR 603 Week One: Compare and Contrast Dementia and Delirium

NR 603 Week One: Compare and Contrast Dementia and Delirium For the purpose of this assignment, I will be comparing and contrasting dementia and delirium which is the topic I was assigned this week. I will review a basic presentation of both diseases/conditions including a review of demographics, onset of symptoms and associated risk factors. I will also review the pathophysiology, assessment findings, diagnostic testing, diagnosis and treatment according to national guidelines for both conditions. Presentation of Dementia and Delirium Major Neurocognitive Disorder or more commonly known as Dementia, is a collection of symptoms that are caused by a number of disorders that affect the brain (Hollier, 2018). Causes of dementia include but not limited to Alzheimer’s Disease, Vascular Disease, Frontotemporal Lobar Degeneration, Lewy Body Disease, Parkinson’s Disease, Traumatic Brain Injury, Huntington Disease, infection, Prion Disease, and Creutzfeldt-Jakob Disease (Hollier, 2018; Schub & Smith, 2018). The most common cause of dementia is Alzheimer’s disease which accounts of 60 to 80% of all dementia cases (Hollier, 2018). It was estimated that over 35 million people had dementia in 2010 across the world and 50 million people in 2017 with the prevalence expected to double every 20 years which would mean about 65 million cases in 2030 and 115 million cases in 2050 (ASLHA, 2019; Morandi et al., 2018). These numbers are just so shocking to me! Dementia is way more common than I had originally thought. According to the DSM-V, criteria for diagnosis of dementia can be made if there is a cognitive impairment from baseline functioning in one or more of the following areas: language, memory, executive function, attention, purposeful movement and social cognition (American Psychiatric Association, 2013; Hollier, 2018). Some patients with dementia cannot control their emotions and therefore their personality may change (National Institutes of Aging, 2017). Symptoms range based on the severity of dementia with the mildest stage presenting with mild effects on a person’s functioning to the most severe stage were the person may become dependent on others for total care of basic ADLs. Dementia has a slow insidious onset that progressively and chronically gets worse that varies from months to years with no cure unlike delirium (Schub & Smith, 2018). Delirium has an abrupt onset that develops over hours or days and can typically change throughout the day known as sundowning and is characterized by a sudden deterioration in cognitive status with a disturbed level of consciousness (Schub & Smith, 2018). Delirium is an alternation in brain function caused by an illness or physical condition. Delirium is considered a medical emergency since it has been associated with many poor medical outcomes; however, it is not terminal like dementia, but instead is reversible. Delirium can occur at any age, but it is more common in the older adult population and in ICU settings with underlying causes. It was shocking to discover that half of all patients in the ICU are affected by ICU delirium. Dementia is more commonly seen in the older adult population as well but without any evidence of underlying causes (Hollier, 2018). Some common causes of delirium consist of infection, withdrawal from drugs or alcohol, presence of drugs or alcohol, an abrupt change in environment, changes in medication or polypharmacy, sepsis, hypoxia, HIV, stroke, myocardial infarction, increased intracranial pressure, sleep deprivation, UTI, pneumonia and dehydration (Brooke, 2018; Schub & Smith, 2018). Delirium has fluctuating symptoms that can have patterns of disorganized thinking, disorganized speech and changes in orientation that are categorized as either hyperactive, hypoactive, mixed and normal consciousness delirium. Hyperactive delirium symptoms can present as fidgeting, restlessness, resistance and possible aggressiveness. Hypoactive delirium symptoms may be characterized inattentiveness and the patient needing to be prompt to eat and drink. Mixed delirium is a mixture of both hypoactive and hyperactive delirium symptoms. Normal consciousness delirium presents as alert and normal appearance but with disorganized thinking and easily distracted. Associated risk factors for dementia consist of age, family history, genetics, history of myocardial infarction or cerebral vascular accident (Hollier, 2018). Whereas, associated risk factors for delirium consist of being hospitalized, being an inpatient in a critical care setting, surgery, being a resident at a nursing home, previous history of delirium episodes, having multiple comorbidity conditions, history of dementia, cerebral vascular accident or Parkinson’s disease (Brooke, 2018). Both conditions have a similar risk factor of CVAs, but most risk factors were different among the two conditions. I also thought it was interesting that dementia is a risk factor for delirium but delirium is not a risk factor for dementia. Pathophysiology, Assessment & Diagnostic Testing As I had mentioned, dementia is a progressive and gradual loss of memory and cognitive skills due to dysfunction and loss of brain cells (ASLHA, 2019; NIA, 2017). As a normal part of aging, nerve cells in the brain stop working and eventually lose connection with other brain cells and die; however, people with dementia experience this loss of neurons at a much greater speed. Delirium is more of an acute and reversible dysfunction of brain activity caused by an impairment of signals in the brain. Assessment and diagnostic testing differ slightly for dementia and delirium. Both should have a history and physical completed; however, the particular screenings and testing used to evaluate the presenting symptoms differ. A thorough physical assessment along with an accurate medical history are essential in differentiating and diagnosing dementia and delirium (Hollier, 2018). Patients with no history or previous cause that presents with memory problems, altered mental status, confusion, disorientation, impaired judgment, hallucinations and behavior changes from baseline should be evaluated for dementia as well as delirium. The focus of the medical history should be on cognitive complaints, functional concerns and behavioral psychiatric symptoms that are not typical of the patient (Hollier, 2018). Additionally, asking family and caregivers of the patient if there is a family history of either dementia or delirium wound be beneficial as well as how and when did the symptoms start and if the patient is taking any medications or treatments that might cause or worsen the symptoms that are present. A complete head-to-toe assessment should be completed as with any patient to identify comorbid conditions that can be contributive to cognitive dysfunction. A cognitive exam and clinical dementia rating scale such as Mini-Mental Status Examination, should be completed to help develop a differential list and rate severity of dementia symptoms (Hollier, 2018; Schub & Balderrama, 2017). A minimum of 2 or more abnormal findings in cognition and behavior on the MMSE is considered a positive diagnosis for dementia. Also, a neurological test should be completed to evaluate vision, balance, coordination and reflexes which can help determine if a CVA or other neurological condition is the cause of the symptoms and can be used for dementia and delirium (NICE, 2018). Further testing can be completed to help rule out other causes of delirium and dementia such as a urinalysis, complete blood count to rule out infection, complete metabolic panel to rule out electrolyte disturbance, thyroid stimulating hormone and free T4 to evaluate for hypothyroidism, lipid panel to rule out hyperlipidemia and coronary artery disease, random glucose or fasting glucose to rule out complications of hypoglycemia or hyperglycemia, an EKG to rule out cardiac arrythmias and myocardial infarction, and vital signs with blood pressure and pulse oximetry which if out of normal range could be a causative factor of the presenting symptoms (NICE, 2018). Additional diagnostic testing specific for delirium could also include ETOH or drug toxicity levels and CT or MRI to rule out brain lesions or tumors (Brooke, 2018). The most commonly used and validated tool for screening for delirium in older adults that are hospitalized is the Confusion Assessment Method or CAM (Brooke, 2018). The CAM can be completed at the bedside to help detect early signs of delirium. Another common and validated screening tool for cognitive impairment and delirium is the 4 As Test or 4AT which is sensitive in detecting delirium in patients with dementia and culturally diverse populations. Diagnosis & Treatment with National Guidelines Dementia and delirium present with profound similar symptoms which makes it extremely difficult in proper diagnosing of the patient (Mendes, 2017). Some of the overlapping symptoms include confusion or disorientation, impaired memory, impaired judgment, and paranoia. Dementia and delirium are diagnosed through a combination of history, physical, cognitive and neurological assessments. Dementia is diagnosed when both cognitive and behavioral symptoms are present which are interfering with the patient’s ability to complete daily activities and when a minimum of 2 or more abnormal findings are found on MMSE (NICE, 2018). Cognitive and behavioral symptoms are unexplained by delirium resulting in a decline from previous baseline levels of function and performance and a definite diagnosis of delirium can be made if results of behavior assessments, CAM or 4AT, are positive for acute onset and inattention combined with either disorganized thinking or altered level of consciousness (Schub & Smith, 2018). Treatment for delirium is dependent on the underlying cause; therefore, when the underlying cause is determined then proper treatment can be initiated with the goal of mental status returning to baseline with recovery (Schub & Smith, 2018). One example of this is if a certain medication was found to be the cause of the delirium in a patient; therefore, that medication was stopped and the patient returned to baseline functioning after stopping the causative agent. Treatment for dementia is targeted at slowing down the progression or worsening of symptoms since dementia is irreversible and a terminal diagnosis (NICE, 2018). In mild to moderate stage dementia, the use of Cholinesterase inhibitors such as Donepezil or Rivastigmine are considered to be the first line treatment. In moderate to severe dementia, NMDA receptor antagonists are ideal such as Memantine to help manage symptoms (NICE, 2018). References