Who Am I? Where Am I?
Facts and Fears About
Dementia and Delirium
November 12, 2007
Karen Rose, PhD, RN
Dorothy Tullmann, PhD, RN
Assistant Professors of Nursing
University of Virginia
Presentation Objectives
Dementia
– Focus on long-term aspects of caring for
persons with dementia
– Emphasize caregiving environment
Delirium
– How delirium differs from dementia
– Importance of early recognition of delirium
What is Dementia
Dementia is a general term for the loss of memory and
other intellectual abilities serious enough to interfere with
daily life.
Classifications
– Alzheimer’s disease (AD): 50% - 70% of all
dementias
– Vascular dementia
– Mixed dementia
– Frontotemporal lobe dementia
– Lewy Body dementia
– Mild cognitive impairment
– Others
How Common is Dementia?
< 65 years
Rare
– Less than 4% of all cases of dementia
65 – 85 years
10%
– At age 65, risk increases 1% per year
86 – 100+ years
50%
– At age 86, risk increases 11% per year
The fear of developing dementia is FAR greater!!
Alzheimer’s Quiz!
Fact or Fiction?
1. Memory loss is a natural part of the aging
process.
2. Alzheimer’s is a fatal disease.
3. All relatives of Alzheimer’s patients inherit
the disease.
4. Alzheimer’s is a disease of the elderly.
5. Life is over upon receiving an Alzheimer’s
diagnosis.
Who Are Caregivers?
Family caregivers are the
mainstay of caregiving support to
persons with dementia.
Over 30 percent of caregivers for
the elderly are, themselves, age
65 years or older.
U.S. Department of Health and Human
Services, 2001
Living with Alzheimer’s
Audio from Vermont Public Radio,
November 6, 2007
Benefits of Caregiving
Psychological
– Self-worth
– Altruism
– Connection with care recipient
Economic
– Costs of care at home vs. costs of care in institutions
Home care: ≈ $19,000 / year
In California alone, cost of care is 2.1 billion now;
4.6 billion in 2020.
Alzheimer’s Association, 2006; Fox et al., 2001
Perils of Caregiving
Physical
– Increased risks for:
Cardiovascular disease
Metabolic syndrome
Other co-morbidities
Mortality
Psychological
– Increased incidence of:
Anxiety
Depressive symptoms
Connell et al., 2001; Gallicchio, 2002; Irwin, 2001; Schulz &
Beech, 1999
Caring for the Caregiver
Importance of caring for self
– For you
– For them
Community resources
– One size does not fit all
Importance of Caregiving
Environment
Socialization (Zarit et al., 2004).
Activities (Rentz et al., 2002; Palo-Bengtsson & Ekman, 2002).
Mental & Physical Stimulation (Camp et al., 1997).
Sleep (Richards, Beck, et al., 2001).
When Things Go Bad
Dementia is a PROGRESSIVE loss of memory and
function….
– When changes are abrupt: Something’s wrong!!
What is Delirium?
“Semantic muddle”
– Acute brain syndrome
– Acute confusion
– Acute confusional states
– Acute brain failure
– ICU (intensive care unit) psychosis
– Sundowner syndrome
Lipowski, 1990
Definition of Delirium
Reduced level of consciousness
– difficulty focusing, shifting or sustaining attention
Cognitive change
– deficit of language, memory, orientation, perception;
not attributed to dementia
Develops rapidly (hours to days)
– varies during the day
General medical condition has directly caused
the condition
American Psychological Association,
2002
Variations of Delirium
Hyperactive
– Increased responsivity to stimuli; hyperalert
– Moves constantly; may be combative
Hypoactive
– Quiet and listless; hypoalert
– Appears indifferent, oblivious
Mixed
– Alternates irregularly
American Psychological Association,
2000
How Does Delirium Differ from
Dementia?
Delirium
Rapid onset
Fluctuates; worse at
night
Altered level of
consciousness
Easily distracted;
attention impaired
Dementia
Chronic, insidious
Symptoms progressive
but stable
Level of consciousness
usually not affected
Tries hard to do task;
great effort to recall
What Causes Delirium?
The pathogenesis of delirium is unclear.
– Anatomic defects?
Changes in different parts of the brain seen on
diagnostic scans
– Neurotransmitter imbalance?
Serotonin, acetylcholine deficit
Dopamine excess
See Trzepacz, 2000 in “Further Reading”
– Genetic predisposition?
Who is At Risk for Delirium?
Predisposing factors
– Age (60+ years)
– Brain damage
– Chronic brain disease (e.g. Alzheimer’s)
Precipitating factors (organic causes)
–
–
–
–
Primary cerebral disease
Systemic diseases affective brain (e.g. sepsis)
Drug, poison intoxication (e.g. polypharmacy)
Withdrawal from substances of abuse (especially
alcohol and sedative-hypnotics)
Lipowski, 1990; Inouye et al, 1999
Facilitating factors
– Psychosocial stress
– Sleep deprivation
– Sensory underload or overload
– Immobilization
Lipowski, 1990; Inouye et al., 1999
Delirium in ICU
New instrument to screen for delirium in ICU
(non-verbal patients)
– Higher mortality rate
– Long-term cognitive and functional decline
Mechanically ventilated patients
– > 80% had at least one day of delirium
– Related to intravenous sedation
In ICU patients, 65+ years
– 31% had delirium on admission to the ICU
– 31% developed delirium in ICU
Ely et al., 2001, 2004; McNicoll et al.,
2003
What Can Be Done in the Hospital?
Early recognition
Treat underlying condition
– Medication reaction
– Infection
Non-pharmacologic management
Medication (antipsychotics, sedatives)
should be a last resort.
What Can I Do?
If you see rapid mental changes, report
them.
– The changes could signal an undetected
illness or other physiologic problem.
Delirium may be prevented or slowed.
– Minimize psychosocial stress
– Avoid sleep deprivation
– Avoid sensory underload or overload
– Avoid immobilization
– Frequent reorientation
Thank you!
Questions?