Who Am I? Where Am I?Who Am I? Where Am I?Facts and Fears AboutFacts and Fears AboutDementia and DeliriumDementia and Delirium

November 12, 2007November 12, 2007

Karen Rose, PhD, RNKaren Rose, PhD, RNDorothy Tullmann, PhD, RNDorothy Tullmann, PhD, RN

Assistant Professors of NursingAssistant Professors of NursingUniversity of VirginiaUniversity of Virginia

Presentation ObjectivesPresentation Objectives

DementiaDementia– Focus on long-term aspects of caring for Focus on long-term aspects of caring for

persons with dementiapersons with dementia– Emphasize caregiving environmentEmphasize caregiving environment

DeliriumDelirium– How delirium differs from dementiaHow delirium differs from dementia– Importance of early recognition of deliriumImportance of early recognition of delirium

What is DementiaWhat is Dementia

Dementia is a general term for the loss of memory and Dementia is a general term for the loss of memory and other intellectual abilities serious enough to interfere with other intellectual abilities serious enough to interfere with daily life.daily life.

ClassificationsClassifications– Alzheimer’s disease (AD): 50% - 70% of all dementiasAlzheimer’s disease (AD): 50% - 70% of all dementias– Vascular dementiaVascular dementia– Mixed dementiaMixed dementia– Frontotemporal lobe dementiaFrontotemporal lobe dementia– Lewy Body dementiaLewy Body dementia– Mild cognitive impairmentMild cognitive impairment– OthersOthers

How Common is Dementia?How Common is Dementia?

< 65 years< 65 years Rare Rare – Less than 4% of all cases of dementiaLess than 4% of all cases of dementia

65 – 85 years65 – 85 years 10% 10% – At age 65, risk increases 1% per yearAt age 65, risk increases 1% per year

86 – 100+ years86 – 100+ years 50% 50% – At age 86, risk increases 11% per yearAt age 86, risk increases 11% per year

The fear of developing dementia is The fear of developing dementia is FARFAR greater!! greater!!

Alzheimer’s Quiz!Alzheimer’s Quiz!

Fact or Fiction?Fact or Fiction?1. Memory loss is a natural part of the aging 1. Memory loss is a natural part of the aging

process.process.2. Alzheimer’s is a fatal disease.2. Alzheimer’s is a fatal disease.3. All relatives of Alzheimer’s patients inherit 3. All relatives of Alzheimer’s patients inherit

the disease.the disease.4. Alzheimer’s is a disease of the elderly.4. Alzheimer’s is a disease of the elderly.5. Life is over upon receiving an Alzheimer’s 5. Life is over upon receiving an Alzheimer’s

diagnosis.diagnosis.

U.S. Department of Health and Human U.S. Department of Health and Human Services, 2001Services, 2001

Who Are Caregivers?Who Are Caregivers?

Family caregivers are the Family caregivers are the mainstay of caregiving support to mainstay of caregiving support to persons with dementia. persons with dementia.

Over 30 percent of caregivers for Over 30 percent of caregivers for the elderly are, themselves, age the elderly are, themselves, age 65 years or older.65 years or older.

Living with Alzheimer’sLiving with Alzheimer’s

Audio from Vermont Public Radio, Audio from Vermont Public Radio, November 6, 2007November 6, 2007

Benefits of CaregivingBenefits of Caregiving

PsychologicalPsychological– Self-worthSelf-worth– AltruismAltruism– Connection with care recipientConnection with care recipient

EconomicEconomic– Costs of care at home vs. costs of care in institutionsCosts of care at home vs. costs of care in institutions

Home care: ≈ $19,000 / yearHome care: ≈ $19,000 / yearIn California alone, cost of care is 2.1 billion now; In California alone, cost of care is 2.1 billion now; 4.6 billion in 2020.4.6 billion in 2020.Alzheimer’s Association, 2006; Fox et al., 2001Alzheimer’s Association, 2006; Fox et al., 2001

Perils of CaregivingPerils of Caregiving

PhysicalPhysical– Increased risks for:Increased risks for:

Cardiovascular diseaseCardiovascular diseaseMetabolic syndromeMetabolic syndromeOther co-morbiditiesOther co-morbiditiesMortalityMortality

PsychologicalPsychological– Increased incidence of:Increased incidence of:

AnxietyAnxietyDepressive symptomsDepressive symptoms

Connell et al., 2001; Gallicchio, 2002; Irwin, 2001; Schulz & Connell et al., 2001; Gallicchio, 2002; Irwin, 2001; Schulz & Beech, 1999Beech, 1999

Caring for the CaregiverCaring for the Caregiver

Importance of caring for selfImportance of caring for self– For youFor you– For themFor them

Community resourcesCommunity resources– One size does not fit allOne size does not fit all

Importance of Caregiving Importance of Caregiving EnvironmentEnvironment

Socialization Socialization (Zarit et al., 2004).(Zarit et al., 2004).

Activities Activities (Rentz et al., 2002;(Rentz et al., 2002; Palo-Bengtsson & Ekman, 2002).Palo-Bengtsson & Ekman, 2002).

Mental & Physical Stimulation Mental & Physical Stimulation (Camp et al., 1997).(Camp et al., 1997).

Sleep Sleep (Richards, Beck, et al.,(Richards, Beck, et al., 2001).2001).

When Things Go BadWhen Things Go Bad

Dementia is a PROGRESSIVE loss of memory and Dementia is a PROGRESSIVE loss of memory and function….function….

– When changes are abrupt: Something’s wrong!! When changes are abrupt: Something’s wrong!!

Lipowski, 1990Lipowski, 1990

What is Delirium?What is Delirium?

““Semantic muddle”Semantic muddle”– Acute brain syndromeAcute brain syndrome– Acute confusion Acute confusion – Acute confusional statesAcute confusional states– Acute brain failureAcute brain failure– ICU (intensive care unit) psychosisICU (intensive care unit) psychosis– Sundowner syndromeSundowner syndrome

American Psychological Association, 20American Psychological Association, 200202

Definition of DeliriumDefinition of Delirium

Reduced level of consciousnessReduced level of consciousness– difficulty focusing, shifting or sustaining attentiondifficulty focusing, shifting or sustaining attention

Cognitive change Cognitive change – deficit of language, memory, orientation, perception; deficit of language, memory, orientation, perception;

not attributed to dementianot attributed to dementia

Develops rapidly (hours to days)Develops rapidly (hours to days)– varies during the dayvaries during the day

General medical condition has directly caused General medical condition has directly caused the condition the condition

American Psychological Association, 20American Psychological Association, 200000

Variations of DeliriumVariations of Delirium

HyperactiveHyperactive– Increased responsivity to stimuli; hyperalertIncreased responsivity to stimuli; hyperalert– Moves constantly; may be combativeMoves constantly; may be combative

HypoactiveHypoactive– Quiet and listless; hypoalertQuiet and listless; hypoalert– Appears indifferent, obliviousAppears indifferent, oblivious

MixedMixed– Alternates irregularlyAlternates irregularly

How Does Delirium Differ from How Does Delirium Differ from Dementia?Dementia?

DeliriumDelirium

Rapid onsetRapid onset

Fluctuates; worse at Fluctuates; worse at nightnight

Altered level of Altered level of consciousnessconsciousness

Easily distracted; Easily distracted; attention impairedattention impaired

DementiaDementia

Chronic, insidiousChronic, insidious

Symptoms progressive Symptoms progressive but stablebut stable

Level of consciousness Level of consciousness usually not affectedusually not affected

Tries hard to do task; Tries hard to do task; great effort to recallgreat effort to recall

What Causes Delirium?What Causes Delirium?

The pathogenesis of delirium is unclear. The pathogenesis of delirium is unclear. – Anatomic defects?Anatomic defects?

Changes in different parts of the brain seen on Changes in different parts of the brain seen on diagnostic scansdiagnostic scans

– Neurotransmitter imbalance?Neurotransmitter imbalance?Serotonin, acetylcholine deficitSerotonin, acetylcholine deficit

Dopamine excessDopamine excess

See Trzepacz, 2000 in “Further Reading”See Trzepacz, 2000 in “Further Reading”

– Genetic predisposition?Genetic predisposition?

Lipowski, 1990; Inouye et al, 1999Lipowski, 1990; Inouye et al, 1999

Who is At Risk for Delirium? Who is At Risk for Delirium?

Predisposing factorsPredisposing factors– Age (60+ years)Age (60+ years)– Brain damageBrain damage– Chronic brain disease (e.g. Alzheimer’s)Chronic brain disease (e.g. Alzheimer’s)

Precipitating factors (organic causes)Precipitating factors (organic causes)– Primary cerebral diseasePrimary cerebral disease– Systemic diseases affective brain (e.g. sepsis)Systemic diseases affective brain (e.g. sepsis)– Drug, poison intoxication (e.g. polypharmacy)Drug, poison intoxication (e.g. polypharmacy)– Withdrawal from substances of abuse (especially Withdrawal from substances of abuse (especially

alcohol and sedative-hypnotics)alcohol and sedative-hypnotics)

Lipowski, 1990; Inouye et al., 1999Lipowski, 1990; Inouye et al., 1999

Facilitating factorsFacilitating factors– Psychosocial stressPsychosocial stress– Sleep deprivationSleep deprivation– Sensory underload or overloadSensory underload or overload– ImmobilizationImmobilization

Ely et al., 2001, 2004; McNicoll et al., 2Ely et al., 2001, 2004; McNicoll et al., 2003003

Delirium in ICUDelirium in ICU

New instrument to screen for delirium in ICU New instrument to screen for delirium in ICU (non-verbal patients)(non-verbal patients)– Higher mortality rateHigher mortality rate– Long-term cognitive and functional declineLong-term cognitive and functional decline

Mechanically ventilated patientsMechanically ventilated patients– > 80% had at least one day of delirium> 80% had at least one day of delirium– Related to intravenous sedationRelated to intravenous sedation

In ICU patients, 65+ yearsIn ICU patients, 65+ years– 31% had delirium on admission to the ICU31% had delirium on admission to the ICU– 31% developed delirium in ICU31% developed delirium in ICU

What Can Be Done in the Hospital?What Can Be Done in the Hospital?

Early recognitionEarly recognition

Treat underlying conditionTreat underlying condition– Medication reactionMedication reaction– InfectionInfection

Non-pharmacologic managementNon-pharmacologic management

Medication (antipsychotics, sedatives) Medication (antipsychotics, sedatives) should be a should be a last resort.last resort.

What Can I Do?What Can I Do?

If you see rapid mental changes, report If you see rapid mental changes, report them.them.– The changes could signal an undetected The changes could signal an undetected

illness or other physiologic problem.illness or other physiologic problem.

Delirium may be prevented or slowed.Delirium may be prevented or slowed.– Minimize psychosocial stressMinimize psychosocial stress– Avoid sleep deprivationAvoid sleep deprivation– Avoid sensory underload or overloadAvoid sensory underload or overload– Avoid immobilizationAvoid immobilization– Frequent reorientationFrequent reorientation

Thank you!Thank you!

Questions?Questions?