Here’s an update on the delirium and dementia (oops, I meant major neurocognitive disorder as per DSM-5) lecture for medical students using WordPress Presentation Shortcode. It’s not the same as PowerPoint–but close. I didn’t use bullets because then you’d have to click the navigation arrows each and every time for each separate bulleted line. We can do without that.
Yes, you heard that right. I don’t think I mumbled. I said…presentation shortcode is…BACK!
As always with this presentation shortcode thingy, you have to right-click on the URL links in just the right spot to make them work. If you want to see the slideshow in full screen, click the 4 arrrow icon in the lower right hand corner. Hit ESC to exit full screen. Slides are easier to see in full screen.
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Delirium & Major Neurocognitive Disorder for Medical Students
Oh My Gosh; Run for Your Lives! It’s WordPress Presentation Shortcode!
20% prevalence in general hospital up to 80% in ICU
Unrecognized in 32-66%
Most common mental disorder in pts over age 65
Increases length of stay and admit to long term care
increased mortality and persisting cognitive impairment
DSM-5 Diagnostic Criteria
Disturbance in attention
Develops acutely over hours to days and fluctuates
Marked by other disturbances: memory impairment, visual perceptual disturbance, disorientation
Not better accounted for another mental disorder
Evidence from H&P, labs showing a medical cause(s)
Pathophysiology of Delirium
Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in multi-lingual elderly Int J Geriatr Psychiatry 2000; 15(11):1021.
Months of the Year Backward (MOTYB)
See great video demo by Drs. Alex Gamble & Paul Thisayakorn of how to administer the Mini-Cog, https://thepracticalpsychosomaticist.com/2011/09/28/lightning-fast-mini-cog-video-featuring-drs-paul-thisayakorn-and-alex-gamble/
Can also ask patient to recite months of year backward, see ref
Treat underlying medical causes; check the medication list and simplify
Antipsychotics are not the treatment for delirium but help manage agitation
Haloperidol not FDA-approved but used for many years; cardiac monitoring if used IV
Atypical antipsychotics helpful; FDA Black Box Warning: increased mortality risk when used in demented elderly
Benzodiazepine for alcohol withdrawal delirium
Estimated 30-40% cases of delirium preventable
Frequent orienting and familiar objects
Consistent nursing staff family involvement
Encourage normal sleep/wake cycle preferably with non-drug intervention
Hearing aids, eyeglasses available
Prevent organic drivers: hypoxia, acidosis, infection
Avoid or minimize exposure to deliriogenic drugs, e.g, opioids, sedative-hypnotics
Major Neurocognitive Disorder (formerly dementia)
In the Diagnostic and Statistical Manual (DSM)-IV, cognitive decline called “Dementia”
In the DSM-5, called “Major Neurocognitive Disorder (MND)
Evidence for significant cognitive decline
Cognitive deficits interfere with function
The deficits don’t occur exclusively in context of delirium
The deficits are not better explained by another mental disorder, e.g., depression
Specifiers now include Alzheimer’s disease, Lewy body disease, vascular disease, etc.
Neurocognitive Disorders as a Consequence of Delirium
“Recent research has demonstrated the presence of cognitive impairment in many patients following Intensive Care Unit (ICU) long-term care. Although estimates differ, it appears that at least 1 in 3 survivors of critical illness will experience long-term cognitive impairment of a severity consistent with mild to moderate dementia. Among specific populations, such as patients with Acute Respiratory Distress Syndrome (ARDS), the prevalence of cognitive dysfunction is even greater and may be as high as 80%.” From “Cognitive Impairment Following ICU Hospitalization” on ICU Delirium web site, http://www.mc.vanderbilt.edu/icudelirium/outcomes.html
Features of Major Neurocognitive Disorders (MND)
SHORT TERM RECALL is a problem
Preservation of long-term memories, vocabulary
Trouble with complex planning, new learning
Some complex tasks may be overlearned, appear easy
But new environments / changes are troublesome
Prevalence 5%-10% in 7th decade; 25% thereafter
Features of Major Neurocognitive Disorders cont.
Lewy Body Disease
Often resembles delirium
May have visual hallucinations, fluctuation in attention, disorganization
Parkinsonism with severe extrapyramidal side effects from conventional antipsychotics
Features of Major Neurocognitive Disorders cont.
MND, Vascular disease
Loss of memory or other thinking skills
Coronary artery disease
E.g. heart attack, angioplasty, heart surgery
High blood pressure
Previous strokes or ‘small stroke’ events
May combine with Alzheimer’s disease too
Psychiatric Symptoms & Behavioral Disturbances in MND
Psychiatric symptoms, e.g., anxiety, depression, personality changes, can precede dx of MND by a year and a half
What to Do: Behavioral Disturbances
Try to remove things that aggravate
Consider pain, medical conditions, hunger, thirstFood refusal, resisting cares such as bathing
Remember not to TEACH
Don’t remind patients of painful events
E.g. that their parents are deceased
Try to distract to something else
Anticipate, Tolerate, and Don’t Agitate model, https://thepracticalpsychosomaticist.com/2012/07/28/and-another-spectacular-video-from-the-grecc-agitation-in-the-hospitalized-older-patient