Open education forum presentation by Dr. Christine Tomkinson on care of the older confused adult. Uploaded with permission, free to distribute.

1. D r . C h r i s t i n e T o m k i n s o n , B S c B M B S
A d u l t N e u r o l o g y R e s i d e n t ,
M c M a s t e r U n i v e r s i t y
O n t a r i o , C a n a d a
Confusion in the Older Adult

2. 76 yr old woman with confusion…
 Focused Medical History
 Duration?
 Constant or fluctuating?
 ROS – fever, malaise, cough, dysuria,
recent trauma

3. 76 yr old woman with confusion…
 Past Medical History
 Previous similar episodes?
 Known dementia diagnosis?
 If so, what’s different today?

4. 76 yr old woman with confusion…
 Medications
 List of medications; any recent changes?
 Who controls meds and how are they given (blister pack, etc)
 Any concerns with med administration?
 Look at meds – more/less than expected?

5. 76 yr old woman with confusion…
 Social History
 Who lives with her?
 Recently widowed?
 Social outlets?
 Diet, alcohol use

6. Delirium
 Disturbance in consciousness, with reduced ability
to focus, sustain, or shift attention
 Change in cognition or development of a perceptual
disturbance
 Disturbance develops over short period of time
(hrs to days)
 Fluctuates during course of day
 Caused by a medical condition, substance
intoxication or medication side effect

7. Why do we care?
 10-15% prevalence in general medical/surgical in
patients
 Approx 30% of older patients during a hospital stay
 60-70% in ICU
 80-90% palliative care
 Increased length of hospital stay, institutional
discharge, mortality

8. Clinical Features
 D – Disordered thinking
 E – Euphoria, Emotions (fearful, depressed, angry)
 L – Language impaired (dysarthia, dysnomia)
 I – Illusions, delusions, hallucinations
 R – Reversal of sleep-wake cycles
 I – Inattention/Distractible
 U – Unaware and disoriented
 M – Memory deficits

10. Causes of Delirium - DIMS
 Drugs
 New medications, Interactions
 Overdose/Withdrawal
 Side effects **Anticholingerics
 Poisons

11. Causes of Delirium - DIMS
 Infectious/Inflammatory
 Sepsis
 Meningitis/Encephalitis
 UTI/Pneumonia/Cellulitis

12. Causes of Delirium - DIMS
 Metabolic
 Electrolyte disturbance
 Hyper/Hypo-glycemia
 Hypercarbia
 Hypoxemia
 Endocrine – Thyroid, Parathyroid, Pituitary, Adrenal
 Systemic organ failure – Liver/Renal
 Nutritional – Wernicke’s (Thiamine), B12, Folate

13. Causes of Delirium - DIMS
 Structural
 Head injury – SAH, SDH
 Stroke, Seizure
 Space occupying lesion – Neoplasm, Abscess

14. Risk Factors
Predisposing Factors Precipitating Factors
Underlying brain diseases (dementias) Polypharmacy
Advanced age Infection
Sensory impairment Dehydration
Immobility
Malnutrition
Catheter use
Hospitalization/Nursing home

15. Dementia
 Development of multiple cognitive deficits
 Memory impairment
 At least one of:
 Aphasia
 Apraxia
 Agnosia
 Disturbance in executive function
 Gradual onset and progressive decline

16. Epidemiology
 Estimated 35.6 million people worldwide (2010)
 Total projected to double every 20 years
 In Middle East and North African countries, projected increase
of 125%
Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization report. Alzheimers Res Ther, 2012. 4(5)

17. Epidemiology
 Approx 15% over age 65
 Incidence doubles every 10 years after 60
 50% prevalence over age 90
 Prevalence increased in Down Syndrome and head
injury (AD)

18. Types of Dementia
 Alzheimer’s Disease – 60-80%
 STM loss (anterograde amnesia)
 Loss of visuospatial skills, insight, executive functioning,
apraxia
 Vascular Dementia (multi-infarct) – 10-20%
 Abrupt onset and stepwise deterioration
 Focal findings/Deficits specific to area affected
 May have vascular risk factors or stroke history
 Mixed

19. Types of Dementia
 Frontotemporal Dementia – 10%
 Disinhibition, socially inappropriate
 Emotional lability
 Progressive expressive aphasia
 Memory preserved
 Lewy Body Dementia – 15-25%
 Fluctuating cognition/attention with progressive decline
 Visual hallucinations
 Parkinsonism
 Parkinson’s related Dementia

20. Reversible Dementia
 Normal Pressure hydrocephalus
 Vitamin deficiencies
 Wernicke-Korsakoff’s (Thiamine – EtOH)
 B12, Folate
 Medications
 Thyroid dysfunction
 Hypo/Hyper-glycemia
 Cortisol
 Depression
 Heavy metals

22. So what should you check?
 Collateral history from family member
 Vital signs
 Temperature
 Glucose
 SpO2
 GEMS Diamond

23. Management of a Confused Adult
 Well-lit, quiet room
 Get down to the patient’s level
 Hearing aids/Glasses
 Reverse stethoscope if needed
 Talk slowly, clearly and use plain language

24. Management of a Confused Adult
 Give them time to process questions
 Orient and re-orient; use family members
 Avoid restraints, catheters, lines
 Stop unnecessary meds
 Treat underlying causes

25. References
Atia M, Rastin T, and Scott C. Neurology. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc.,
Toronto 2011. p.10-15.
VIHA. CAM v3 Delirium in the older person: a medical emergency. www.viha.ca/mhas/resources/delirium/
(Accessed June 30,2014)
Francis J and Young GB. Diagnosis of delirium and confusional states. In: UpToDate, Wilterdink JL (Ed),
UpToDate, Waltham, MA. (Accessed June 26, 2014).
Harrington, C.J. and K. Vardi, Delirium: presentation, epidemiology, and diagnostic evaluation (part 1). R I Med
J (2013), 2014. 97(6): p. 18-23.
Hake AM and Farlow MR. Clinical features and diagnosis of dementia with Lewy bodies. In: UpToDate, Eichler AF
(Ed), UpToDate, Waltham, MA (Accessed July 1, 2014).
Holiff J, White M, and Wilson KR. Psychiatry. In: Toronto Notes, 27th Ed, Toronto Notes for Medical Students Inc,
Toronto 2011. p.17-19.
Shadien MF and Larson EB. Risk factors for cognitive decline and dementia. In: UpToDate, Eichler AF (Ed),
UpToDate, Waltham, MA (Accessed June 30,2014).
World Health Organization. Dementia: A public health priority. WHO Press, Geneva 2012.
Wortmann, M., Dementia: a global health priority - highlights from an ADI and World Health Organization
report. Alzheimers Res Ther, 2012. 4(5): p. 40.
Wright CB. Etiology, clinical manifestations, and diagnosis of vascular dementia. In: UpToDate, Eichler AF (Ed),
UpToDate, Waltham, MA (Accessed July 1, 2014).