# 011 Diagnosing Dementia in Acutely Ill Elderly Patients

Fast Facts and Concepts #011 PDF

Authors: Kathryn Denson, MD, John Petronovich, Bambi Wessel

Objectives:

1. Identify the association between dementia and delirium.
2. Recognize the increased morbidity and mortality of patients with delirium.
3. List practical strategies to determining whether an acutely ill patient has an underlying dementia.

ACGME Competencies: Patient Care; Medical Knowledge

Context: Cognitive Assessment of the Acutely Ill Elderly Patient

Action: Using history taking and physical exam skills to determine underlying cognition in acutely ill elderly patients.

Incidence/Prevalence : An elderly patient's baseline cognitive status may not be immediately evident on initial clinical presentation. A patient's cognition at the time of initial evaluation may be clouded by medical conditions (e.g., electrolyte disturbances, infections, hypoxia, medications), psychological conditions (e.g., depression), or surgical conditions (e.g., trauma, other medical issues requiring surgical treatment). These, and many other, conditions may induce delirium in elderly patients, obscuring presentation of an underlying

dementia. Over 30% of elderly patients experience delirium during hospitalization1. Assessment of a patient's baseline mental status is vital, as two thirds of confirmed cases of delirium occur in patients with baseline dementia2. Identification of patients with underlying dementia permits enhanced efforts for delirium reduction and management efforts. Hospitalized patients with a diagnosis of delirium have a mortality rate between 10-26% 3.

Underlying Science: Delirium is a disorder of cognition characterized by transient and partially reversible neuropsychiatric abnormalities. Factors that may trigger delirium include medications, infection, immobility, electrolyte imbalances, malnutrition, and disruption of circadian rhythm. While the pathogenesis of delirium is poorly understood, several theories do exist. The presence of delirium is associated with drugs, infections, or other processes that alter concentrations of neurotransmitters in the brain, including2:

1. Acetylcholine: Decreases may cause excessive neuronal excitability.
2. Dopamine: Increases may cause a decrease in the release of acetylcholine.
3. GABA: Decreases may cause excessive neuronal excitability.
4. Serotonin, endorphins, cortisol, neuropeptides, and pro-inflammatory cytokines: theorized, but not clearly defined mechanisms.

Despite the strong association between dementia and delirium, a causative relationship remains unclear. Regardless, instances of delirium in a patient with dementia can worsen the dementia at baseline.

Assessment: The diagnosis of dementia may be challenging in an acutely ill, or perhaps delirious, patient. A practical approach includes using the history and physical exam to look for clues to underlying dementia.

1) History:

The diagnosis of dementia may be challenging in an acutely ill, or perhaps delirious, patient. A practical approach includes using the history and physical exam to look for clues to underlying dementia.

History:

1. Interview the patient (if possible), and any family and/or caregivers (corroborative history is a must) regarding:

1. Baseline memory and thinking/problem solving abilities
2. Changes in personality (may indicate dementia)
3. Changes in mood (may occur with/prior to dementia)
4. Activities of daily living (ADLs) and instrumental activities of daily living(IADLs). Document decline in abilities to care for self or perform tasks

2. Review chart documentation for a diagnosis of dementia, memory loss or confusion

3. Review chart documentation for any cognitive testing scores

1. Bedside/office mental status examinations such as MOCA (Montreal cognitive assessment) or MMSE (Folstein Mini-Mental Status Exam)
2. Formal neuropsychiatric testing

4. Contact the patient's primary physician and ask about the patient's cognition and functioning.

5. Review the medication list for medications used to treat dementia or behaviors associated with dementia.

2) Physical Exam:

Cognitive testing is challenging in acutely ill patients. If the patient is delirious, cognitive testing may indicate abnormalities in thinking, but this testing is not a reliable measurement of underlying dementia. Dementia is best diagnosed by past history or cognitive examination of the patient when he/she is at cognitive baseline.

References:

1. Francis J. Delirium in older patients. Journal of American Geriatric Society 1992; 40:82
2. Inouye SK. Delirium in older persons. N England J Med. 2006; 354:115
3. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med. 2002;162(4):457-63.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

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