Delirium, an acute confusional state, is a clinical syndrome characterized by fluctuating attention and confusion. It develops quickly, over hours to days, its duration is highly variable. Delirium can present with hypoactive, hyperactive, or mixed states. It can be triggered by medication, physiologic or psychologic stress, or illness. Delirium is generally reversible with treatment of the precipitating factor but some chronic cases have been identified. Longer duration is directly associated with worse short and long-term outcomes. Delirium is common, although far from normal, in older adults. It is more common in individuals who also have dementia.1,2
Dementia is an acquired, gradual loss of memory and cognitive function. It characteristically includes impairment of a major cognitive domains, such as language, visual perception, and executive function. The cognitive impairment is not attributable to any other cognitive disorder.3
Mild cognitive impairment (MCI) is characterized by a decline in memory or other cognitive domains while overall function is relatively preserved. That is, there is objective impairment in one or more cognitive domains while there are no significant impairments in instrumental activities or daily living. No features of global cognitive impairment are present. Older adults with MCI are at increased risk for progressing to dementia. Individuals with MCI and other risk factors for dementia require close monitoring.4
Delirium’s common triggers include:
- Patient: age 65 years and older; pre-existing cognitive deficits; severity of medical comorbidities; previous episodes; perioperative status.
- Medical/surgical: infection; burns; acquired immune deficiency disease; fracture, particularly hip fracture; fluid and electrolyte imbalance; organ failure such as cardiac, liver and renal; infection; pain; metabolic causes; immobilization; hypothermia; neurological problem such as acute stroke.5
- Pharmacological: poly-pharmacy; drug/alcohol use; drug/alcohol withdrawal. Medications that are on the list of Beers Criteria due to high potential for causing confusion are likely to be triggers. These include: benzodiazepines, anticholinergic agents, opioids, anticonvulsants, lithium, corticosteroids, histamine-2 blockers.2
- Environmental: unfamiliar environment; lack of social interaction; lack of stimulation or orientation cues.
- Psychosocial: psychological or social stressors.5
Etiology and pathophysiology vary with dementia type:
- Alzheimer’s Disease (AD), which accounts for more than 70% of dementia diagnoses, involves abnormal conformation and deposit of tau protein and beta amyloid in neurofibrillary tangles and plaques. These deposits, which affect brain areas including hippocampus, parieto-temporal neocortex, and related connections, interrupt cortical functioning.6,7
- Vascular dementia, which accounts for at least 25% of dementias and likely contributes to others as well, is associated with cerebrovascular disease.8
- Lewy body dementia (LBD), which can comprise 10-15% of dementia cases, involves deposition of alpha synuclein in the cortex and subcortex of the brain.8
- Other dementias, which account for about 5% of total cases, include fronto-temporal dementia, which involves abnormal deposition of tau protein.
- Rarer entities include dementia associated with Huntington’s disease and prion diseases like Cruetzfeld Jacob Disease.8
Mild cognitive impairment
The etiology is not certain, but is likely very similar to dementia.
Epidemiology including risk factors and primary prevention
Delirium is the most common complication of hospitalization for older adults. It occurs in all areas of the hospital, from the emergency department to intensive care units. It has been noted in more than 50% of older adults who have had surgeries such as hip or vascular procedures. In general medical units, its prevalence is estimated at more than 30%. It affects about 15% of older adults in long-term care settings.9
Specific factors that tend to put patients at more risk for delirium include absence of clock, hearing aids or glasses; physical and chemical restraints; change in location within hospital; acute illness; and physical and environmental stressors.5
Primary prevention measures include identifying patients who are at risk for delirium and modifying environments to optimize orientation and normal sleep-wake cycles.
Medications with high potential to cause delirium should be used with caution. Underlying conditions should be treated promptly.2
Dementia affects approximately 20% of individuals over 80 years of age. As more people reach older age, the prevalence of symptomatic neurodegenerative diseases will likely increase substantially.10
AD risk factors include advancing age, especially over 85; first degree relatives with onset under the age of 65; apolipoprotein-e4 gene; history of severe traumatic brain injury or multiple repetitive injuries; cerebrovascular disease, homocysteinemia; and low level of education.10 Protective factors for AD may include use of nonsteroidal anti-inflammatory drugs, moderate intake of wine, coffee, and regular exercise.11
For other dementias, risk factors and primary prevention measures include:
- Vascular dementia: risk factors include hypertension, hyperlipidemia and diabetes mellitus. Primary prevention measures include treating these conditions.
- Lewy body dementia is associated with Parkinson’s disease (PD) and may also occur on its own. It is not clear whether treatments for PD have an effect in preventing LBD.
- Huntington’s disease occurs as a result of a genetic abnormality (CAG trinucleotide repeat) that is inherited in an autosomal dominant pattern. Affected individuals generally display some behavioral and motor abnormalities in their thirties or forties. Symptoms tend to progress from there.
- Prion disease, such as Cruetzfeld Jacob, is contracted. One possible source of transmission is through brain tissue of sheep and cows. Prevention methods have not been definitively established.12
Mild cognitive impairment is estimated to occur in more than 10% of individuals over 70 and 20% of individuals over 80. Primary prevention is similar to the paradigm for dementia in general. This includes treating vascular risk factors and other illnesses, staying cognitively active, and maintaining a program of physical activity over time.13
Delirium can be thought of as a type of acute brain failure. Its pathophysiology may include any factor that interferes with the brain’s homeostasis. Some factors that have been identified and postulated include abnormally active proinflammatory cytokines, oxygen deprivation, sleep-wake cycle abnormalities, and dysregulation of the limbic-hypothalamic-pituitary-adrenal axis. Neurotransmitter abnormalities, such as acetylcholine deficiency; excess dopamine, glutamate, or norepinephrine; and decreased or increased serotonin levels, can also contribute to problems. Lastly, alterations in activity of drug-metabolizing enzymes may explain the unexpected toxicity and adverse effects of otherwise benign medications.2
The abnormal processing or deposition of proteins result in inflammation and cell destruction. The involved proteins vary by type of dementia. Cerebral blood vessels abnormalities negatively affect blood flow through the brain. Neurons both die and become dysfunctional. Communication between neurons and neuronal networks is damaged or lost. Functional sequelae follow.14
Mild cognitive impairment
The pathophysiology is likely similar to what occurs in dementia.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
- Acute/ subacute: At least 50% of affected individuals are improved and back to their baseline one month after developing delirium. Others tend to recover over the next 1 to 3 months.
- Chronic/stable: There are some cases, as many as 10%, where delirium never fully clears and cognitive impairment is noted over the subsequent long-term. It is not yet clear why some individuals do not recover.9
Memory impairment is usually followed by decline in language and visuospatial skills, then executive functions. Neuropsychiatric sequelae such as behavior and personality changes, often. Speech and swallowing issues can occur. Impairments in other aspects of function progress, often in parallel to the cognitive changes. These changes generally occur over 5 to 10 years in AD and Lewy Body, with shorter courses for other dementias, but these durations are highly variable in individual cases.12, 14
Mild cognitive impairment
About 10 to 15% of people with MCI progress to dementia each year. (Burns 2009). MCI also has a strong association with depression. At least 33% of people with MCI also have depression. It is not yet clear whether the relationship between MCI and depression represents some disease progression or an association.15
This table provides a basic summary of the stages of dementia and mild cognitive impairment.
|MEMORY LOSS||Short term||Most short term and some long term||Most short and long term||Almost all short and long term|
|FUNCTIONAL LOSS||Instrumental activities of daily living (IADLs)||Most IADLs and some basic activities of daily living (ADLs)||Basic ADLs||Dependent for all activities|
2. ESSENTIALS OF ASSESSMENT
The patient’s current mental status should be compared to reported baseline. Recent illnesses, treatments, and interventions should be thoroughly explored. Nutrition, bowel/ bladder, hydration status, recent sleep and activity patterns are crucial.5
Other conditions may mimic dementia. These problems, which can include deficiencies of vitamin B1, B12, folate and niacin, anemia, endocrinopathies involving thyroid or adrenal function, medication toxicities, and paraneoplastic phenomena, can reverse with treatment after they are identified. Effective history and assessment, then, are essential.10
History should include discussion of possible subtle functional changes. These can include forgetting appointments, problems with finances, misplacing common objects in odd places, and kitchen mishaps. Generally, patients and families will note a history of progressive memory impairment, followed by impairments in language and visuospatial functioning. Patients may develop inability to recognize faces (prosopagnosia) and objects (visual agnosia), although they may not be aware of the problem. Neuropsychiatric and behavioral changes, which can be most burdensome to families, often follow.10
The history for suspected MCI is similar to that for dementia.
Overlap with depression
Of note, mild cognitive impairment and dementia can have symptoms that overlap markedly with depression. A recent systematic review and meta-analysis demonstrated a 33% prevalance of depression in people with MCI. Individuals who have been diagnosed with dementia may have depression that mimics dementia, a condition termed pseudodementia. It is possible for individuals to be misdiagnosed with MCI or dementia when they actually have depression. It is also possible for MCI or dementia to co-exist with depression. The depression may well make cognitive symptoms seem worse.15
For both MCI and dementia, then, thorough screening for depression is warranted. The Geriatric Depression Scale is one useful tool. Careful history, with focus on symptoms of depression, is also valuable.15 Common symptoms of depression include difficulty sleeping, lack of interest in activities, change in appetite, feeling sad, feeling guilty, difficulty concentrating, thoughts of suicide. Consultation with a psychiatrist or neuropsychologist can be helpful in this complex diagnostic process.16
In cases of suspected delirium, dementia and MCI, a comprehensive physical exam is warranted. Clinicians should pay particular attention to these potential issues, which may either affect the assessment or be cause for additional evaluation:
- Nutritional status and any evidence of self or caregiver-neglect.
- Visual and hearing problems which may inadvertently affect cognitive evaluation.
- New illness/acute exacerbation of chronic diseases.
- Focal neurological signs or symptoms which can herald an underlying abnormality in the brain.12
Clinicians should assess for these delirium-specific functional factors:
- Recent development of confusion that fluctuates.
- Disturbance of consciousness.
- Changes in cognition.
- Underlying medical condition.
Assessment needs to include a determination of which type subtype of delirium is occurring:
- Hyperactive: hallucinations, delusions, agitation and disorientation.
- Hypoactive: lethargy, apathy, sleepiness, decreased interest and motivation.
- Mixed: features of hyperactive and hypoactive at different times.
Functional assessment includes evaluation of current ability to complete activities and instrumental activities of daily living while in this state. Clinicians should also focus on ways to keep delirious individuals safe from harm.1
Cognitive assessment tools, like the Mini-Mental State Examination (MMSE), can prognosticate impairment and functional decline. The functional issues, particularly psycho-behavorial changes, can have the biggest impact on caregivers and the need for institutionalization. Functional assessment, then, is of paramount importance. The following table illustrates the common progression as function is lost during dementia:
|AD||MMSE Score||Impairment||Functional help needed||Caregiver Roles|
|MILD||20 – 26||Short-term recall||Mild functional dependence||Assisting with IADLs such as finances|
|MODERATE||10 – 20||Remote memory impairment||Moderate dependence, especially with hygiene/ ADLs||Driving, shopping|
|SEVERE||< 10||Gait and balance impairment, incontinence, myoclonus||Total mobility dependence||Constant supervision for all activities|
These are performed to exclude other diagnoses, even concurrent ones, that may be reversible. Studies include complete blood count; electrolytes; renal, liver and thyroid function tests; C-reactive protein; folate; B12, calcium; glucose; serologies (syphilis, Lyme); oxygen-hemoglobin saturation; urinalysis; urine and blood cultures.10
Imaging can have a role in excluding other conditions as well as confirming diagnosis.
- Imaging (e.g., chest radiograph) explores medical causes (e.g., pneumonia) of delirium.
- Brain imaging is used to look for other diseases causing cognitive impairment (cerebral infarct/hemorrhage, encephalomalacia from a prior injury, or tumor).
- Amyloid deposition in the brain can be detected by positron emission tomography (PET).
- Single photon emission computed tomography (SPECT) and PET scanning may be able to differentiate dementias. This will likely become more useful in future years, as imaging techniques advance.17
Supplemental assessment tools
Standardized assessments are used to differentiate delirium from other conditions and to track symptom severity over time. Some tools that are commonly used include:
- The Confusion Assessment Method (CAM) screening tool was developed to diagnosing delirium in older adults and is widely used. It has a sensitivity of nearly 90% and positive predictive value for delirium detection of over 75%.18
- The Informant Questionnaire on Cognitive Decline in Elderly (IQCODE) allows caregivers to provide information about 25 everyday activities. It correlates with MMSE scores. 19
- The NEECHAM confusion scale allows nurses to rate behaviors while providing care to hospitalized patients. It was developed for older adults with hip fractures but has been validated in multiple other settings and populations. It examines cognitive processing, behavioral and physiological parameters. It has high inter-rater reliability, 95% sensitivity, 78% specificity, and correlates with MMSE scores.19
- The Delirium Rating Scale (DRS-R-98) both assesses symptom severity and has diagnostic significance. It can classify symptoms as relating to cognition or not. This can help distinguish delirium from dementia, schizophrenia, depression or medical illness. With a sensitivity and sensitivity above 90%, this tool can help helpful.19
- The Memorial Delirium Assessment Scale (MDAS) can measure and track the severity of delirium. It assesses change in level of arousal, cognitive function, and psychomotor activity over time. It can even be used to track changes over the course of a single day. Since scores differ between patients with and without delirium, it can also help with diagnostic issues.19
- The Mini Mental State Exam (MMSE) remains in widespread use. Confounders to its use include language fluency and education level.
- Another commonly used test is the Mini-Cog Assessment Instrument. This has high sensitivity, is time-efficient and not confounded by level of education and native language. It involves repeating three words immediately after presentation; clock drawing; and retrieving the three words presented above. A score of 2 or less (maximum 5) screens positively for dementia.
- A battery of neuropsychological tests is often helpful in clarifying the dementia diagnosis. These tests can be particularly valuable when there are questions about the type of dementia.16
Mild Cognitive Impairment
- The Montreal Cognitive Assessment (MoCA) can effectively screen for MCI. It assesses cognitive domains including short term memory recall, visuospatial abilities, and executive functions such as orientation, language and phonemic fluency, verbal abstraction, sustained attention, attention, concentration and working memory. The MoCA’s sensitivity and specificity for detecting MCI have been reported to be as high as 90% and 87%.20
An environmental assessment is warranted. The healthcare environment can be unfriendly to an older adult’s cognition. Sleep deprivation, lack of orientation, nighttime noise, absence of natural light, inconsistent staff and unfamiliar food can be factors in development or prolongation of delirium. These and other factors can also be anticipated and addressed before they cause significant problems.
It is important to assess the patient’s living environment. Safety can be enhanced by items like wearable alarm systems and supervision around appliances. Assistive devices and falls prevention measures may also be useful.
Social role and social support system
Mild-to-moderate dementias usually can be managed at home, but will likely require a caregiver. Family caregivers need to be assessed for caregiver burden and stress issues, since these can affect their ability to be effective caregivers.14
As dementia progresses, movement to an alternative living setting may be necessary. Some individuals and families prefer to stay at home with help, while others may choose to go to another care setting. Options include adult day health care, assisted living, and subacute care/ nursing home environments. Clinicians can help families through these transitions.14
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
- Treatment strategies for delirium:
- Interdisciplinary teams conduct environmental rounds to detect and address the presence of common triggers.
- Physiologic precipitants should be treated promptly, with minimal use of medications with anticholinergic effects.
- Oxygen status, hydration and nutritional status should be optimized.
- The patient should be mobilized.9
- Using medications in delirium:
- Clinicians working with older adults should keep medications to a minimum, but when medications are indicated, clinicians should start at low doses and titrate up slowly.
- Medications which high potential to cause confusion and other adverse effects should not be first line choices.2
- Medications that may be useful if environmental measures are not sufficient in cases of acute delirium:
- Haloperidol, first generation dopamine antagonist, is limited by medication interactions and its potential to cause prolonged QT interval and extrapyramidal effects.21
- Quetiapine, second generation and atypical dopamine antagonist, has been shown to improve dangerous symptoms at the same rate as haloperidol with fewer side effects.22
- Treatment options for Alzheimer’s dementia: There are two approved classes of medications. The optimal time to start these medications or recommended duration of treatment is not standardized.
- Acetylcholinesterase inhibitors are thought to work by increasing the amount of acetylcholine available to mediate learning and memory. Examples include: donepezil, rivastigmine, and galantamine.
- N-Methyl-D-Aspartate (NMDA) receptor antagonists are believed to block glutamate-mediated excitotoxicity and associated calcium overload, mitochondrial dysfunction, abnormal oxidation, and neuronal apoptosis. One example, memantine, has been shown to have some benefit on cognition, particularly in moderate to severe cases of AD.23
- Dementia- related psychosis: Antipsychotic agents are not routinely recommended for treatment of dementia-related psychosis since these agents are associated with an increased risk of stroke, heart failure, and death.14
- Therapies in dementia:
- Occupational therapy, speech therapy, and other forms of cognitive rehabilitation may be helpful to address short term problems. Patients and families can benefit from recommendations regarding ways to optimize medication adherence and home safety. Adaptive equipment, including cognitive orthotic devices and smartphone applications which can compensate for some cognitive impairments, can also be implemented as indicated.24 A course of cognitive stimulation may also be beneficial.25 The optimal timing and paradigm of treatment has not yet been established.
- Speech therapy can be helpful for individuals who develop dysphagia. Speech therapists can assess swallowing abilities. Food and liquid consistencies may need to be altered to prevent aspiration, optimize safety, and still allow for pleasurable mealtimes. For instance, individuals with cognitive difficulties can benefit from thickened liquids or softer foods. A dietician can provide recommendations for appropriate foods and drinks within the restrictions outlined by the speech therapist.
- Exercise, in the form of regular physical activity, may be protective against cognitive impairment. Multiple studies suggest that there are significant benefits of long-term, regular exercise on cognition and dementia risk. Aerobic exercise, in particular, has the potential to decrease cerebral atherosclerosis effects and resultant negative effects on brain health.13
- In patients with mild cognitive impairment and dementia, programs of sustained exercise over 1 to 12 months have been associated with cognitive improvements.13 In a meta-analysis of studies looking at aerobic exercise programs in people with dementia, there were positive benefits associated with aerobic exercise. Participants were noted to have fewer new cognitive problems, less or slower cognitive decline, and improved overall function.26
- The physiology behind the benefits of exercise may involve bolstering of structures including gray matter and hippocampal structures, better connectivity of neural networks, or effects of increased cerebral oxygenation in settings of better cardiovascular fitness. Some of exercise’s myriad other benefits include decreased osteoporosis and fracture risk, improvements in depression and anxiety, and decreased overall mortality risk.13
- Currently available studies do not yet provide specific parameters for exercise. Clinicians should take individual patients’ needs into account when recommending exercise programs. The risk for possible adverse effects, including falls and acute coronary issues, should be minimized. In general, it seems reasonable and appropriate, based on available information, to recommend aerobic exercise that increases the heart rate, for 20 to 30 minutes per session, at least 3 days per week. The intensity should be individualized based on the person’s status and abilities.11,13 The possible effects of resistance training on cognition have not been extensively studied. (Ahlskog, 2011). Aadapted interventions, such as participating in aerobic exercise with the assistance of a cane or wheelchair, have not been extensively studied. However, clinicians can recommend adapted activities by extracting information from available literature. A key concept is that aerobic activities, in all forms, are likely
- Available evidence suggests that consumption of fruits and vegetables can have benefits for brain health. At this point, however, recommendations regarding optimal dietary intake of fruits and vegetables are not available.27
- For vitamins and micronutrients, on the other hand, Recommended Daily Allowances (RDAs) provide guidelines for optimal intake. Clinicians should encourage individuals to meet their RDAs to avoid nutritional deficiencies and potential sequelae on brain health and function. Supplementing vitamin B12 and vitamin C may be helpful since these are deficient in many older adults’ diets.28
- Individuals with cognitive impairment may develop declines in nutritional intake as their cognition worsens. Sequalae can include unintentional weight loss, malnutrition, and increased morbidity and mortality. Environmental interventions, such as buffet-style and family-style meals, and pleasant music at mealtimes, may help attenuate this problem.29
- MCI generally does not require medical treatment. It is not yet clear whether and how cognitive interventions may help MCI but regular physical activity is likely beneficial.
At different disease stages
The treatment paradigm does not significantly change in prolonged courses compared to the acute phase.
- Individualized general and specific interventions help the patient and family optimize safety and enhance physical and emotional well-being during the course of dementia.14
- Patients, family members and other caregivers, and clinicians often need to address difficult situations as cognition worsens. Physical and sensory limitations and neuropsychiatric symptoms may also develop. Individuals may lose their ability to manage finances or other instrumental activities of daily living.
- Caregivers may need to assist with financial matters. Caregivers may need to enlist legal assistance to ensure that the impaired individual’s own autonomy and preferences are being respected. Neuropsychological assessments, using standardized and validated instruments, can provide some objective data about impairments and abilities which may help inform these complex decisions.16
- Individuals may lose the ability to drive safely in the setting of vision, physical and cognitive problems. A driving evaluation, generally performed by occupational therapists, may be helpful. Clinicians need to partner with families to develop subsequent plans. In some states, clinicians can report concerns to authorities such as Department of Motor Vehicles. In many other states, however, clinicians are not able to report and instead need to ask family members to help enforce recommendations. A social worker or other community resource expert can help identify alternative methods of transportation when needed.
Mild Cognitive Impairment:
- Since individuals with MCI have increased risk of developing dementia, they should undergo regular monitoring. While there are no specific guidelines, clinicians should follow an objective measure every 6 to 12 months or when new symptoms develop.
- There is a notable overlap between MCI and depression. Individuals with MCI, then, require screening and evaluation for depression. If depression is diagnosed, it should be treated. Having both MCI and depression may lead to an even higher risk of MCI progressing to dementia. It is possible, then, that treating the depression can attenuate at least some of that risk.4
Coordination of care
Transitions between hospital units, rehabilitation units, and long-term care facilities should include effective communication and care coordination. Clinicians in receiving units and facilities can then plan for appropriate patient-centered interventions.
Patient & family education
Families may find that the National Institute of Health’s National Institute on Aging-Alzheimer’s Disease Education And Referral Center (ADEAR), and the Alzheimer’s Association and Related Disorders sites can be helpful. Local support groups and resources should also be identified for caregivers.
Caregivers should be educated to look for cognitive decline and to recognize small stressors which can lead to medical and functional decline. Family members should apply strategies to allow uninterrupted sleep and optimal activity levels. Exercise should also be encouraged. Families also need education regarding their need for rest and support to avoid caregiver burnout and related stress.
Assessment and diagnosis of AD:
- Imaging, including MRI and PET scans, may soon be reliably able to describe amyloid plaques and hippocampal volume to aid in AD diagnosis. These tests are not yet routine, but may be used to confirm or clarify aspects of the dementia diagnosis in coming years.30
- Genetic testing
- Testing for the presence of AD dominant mutation in presenilin 1, presinilin 2, or amyloid precursor protein, may also help in confirming diagnosis of AD. 10
- Genetic testing should be obtained in collaboration with appropriate specialists. Genetic counselors can help patients discern their risk prior to testing and can help with test interpretation. Patients and their families need to discuss implications of such testing with each other and with their medical teams prior to being tested and when results come back.17
Overlap and interface between delirium and dementia:
- Dementia is the most common risk factor for delirium. Delirium is an independent risk factor for the subsequent development of dementia. They likely share at least some pathological mechanisms.
- It is possible that applying the principles for preventing and treating delirium more broadly and to well older adults could help develop cognitive reserve and prevent precipitous degrees of cognitive decline in people with dementia.31
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Diagnosis of delirium and dementia can be improved by clinicians becoming more aware of the conditions, educating the public, incorporating cognitive assessment into routine practice, and using available screening instruments.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
- Prevention of delirium with melatonin:
- Melatonin and its precursor, L-Tryptophan, have been trialed as preventive agents in patients who are at risk for delirium. It is possible that the delirious state results from a deficiency of tryptophan and a subsequent serotonin deficiency. Plus, lower melatonin levels could lead to sleep-wake cycle problems. Therefore, supplementing with these agents might be helpful. Trials are ongoing.2
- Complementary medicine interventions for hyperactive delirium/ agitated behaviors:
- Complementary and holistic interventions can include aromatherapy, therapeutic music/dancing, and animal-assisted therapy. Therapeutic touch and tactile stimulation, along with massages of feet, hands, head, and face have also been tried. These interventions should be designed and implemented with the patient’s pre-morbid preferences in mind. Studies regarding efficacy and safety are ongoing.32
- Cognitive stimulation in dementia:
- There is some emerging evidence that multifaceted cognitive stimulation can limit cognitive decline. Interventions can include multi-sensory stimulation with a combination of lighting effects, music or sounds, scents, tactile experiences, and balance challenges. Optimal regimens have not yet been developed.25
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
- MCI’s relationship to dementia:
- MCI appears to be a precursor to dementia, at least in some people. Standard strategies for monitoring, at some point perhaps treating, individuals with MCI would be helpful.
- Physical activity:
- Aerobic exercise has been shown to have benefit on cognition. Additional evidence, and more concrete guidelines for the timing, type, frequency, and intensity of exercise to recommend, are needed.
- Cognitive stimulation:
- Cognitive stimulation and activity may be beneficial for individuals with dementia. Standard recommendations for treatment regimens would help guide care planning.
- Guidelines for genetic testing for Alzheimer’s Disease
- As testing becomes less expensive and more widely available, ethical dilemmas may become more common. For example, an individual may find out that he or she carries a gene that puts him or her at increased risk for AD before symptoms appear. This information could affect decisions made by the individual and family members in other generations who may also have the gene. Guidelines for testing and for addressing positive results could help clinicians effectively navigate these challenging situations.
- De J, Wand APF. Delirium screening: A systematic review of delirium screening tools in hospitalized patients. Gerontologist. 2015;55(6):1079-1099.
- Walker CK, Gales MA. Melatonin receptor agonists for delirium prevention. Ann Pharmacother. 2017; 51(1): 72-78.
- Young J, Meagher D, Maclullich A. Cognitive assessment of older people. Brit Med J. 2011; 343: d5042.
- Mourao RJ, Mansur G, Malloy-Diniz, et al. Depressive symptoms increase the risk of progression to dementia in subjects with mild cognitive impairment: Systematic review and meta-analysis. Int J Geriatr Psychiatry. 2016; 31: 905-911.
- Maclullich AMJ, Anand A, Davis DHJ, et al. New horizons in the pathogenesis, assessment and management of delirium. Age Ageing. 2013; 42: 667-674.
- Fiest KM, Roberts JI, Maxwell CJ, et al. The prevalence and incidence of dementia due to Alzheimer’s disease: A systematic review and meta-analysis. Can J Neurol Sci. 2016; 43: S51-S82.
- Ringman JM. Update on Alzheimer’s and the dementias. Neurol Clin. 2017; 35: 171-174.
- Burns A, Iliffe SK. Alzheimer’s disease. Brit Med J. 2009; 338: b158.
- Young J, Inouye S. Delirium in older people. Brit Med J. 2007; 334: 842-846.
- Dubois B, Padovani A, Scheltens P, et al. Timely diagnosis for Alzheimer’s disease: A literature review on benefits and challenges. J Alzheimer’s Dis.2016; 49:617-631.
- Cass SP. Alzheimer’s disease and exercise: A literature review. Curr Sports Med Rep. 2017; 16(1): 19-22.
- Scott KR, Barrett AM. Dementia syndromes: Evaluation and treatment. Experi Rev Neurother.2007; 7: 407-422.
- Ahlskog JE, Geda YE, Graff-Radford NR, et al. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011; 86: 876-884.
- Seeganna C, Antai-Otong D. Managing the care of the older patient with delirium and dementia. Nurs Clin N Am. 2016; 51(2): 151-164.
- Ismail Z, Elbayoumi H, Fischer C, et al. Prevalence of depression in patients with mild cognitive impairment: A systematic review and meta-analysis. JAMA Psychiatry. 2017; 74: 58-67.
- Lu PH, Lee GJ. The role of neuropsychology in the assessment of cognitively impaired elderly. Neurol Clin. 2017; 35: 191-206.
- Borenstein AR, Mortimer JA. Fluid, imaging, and cognitive biomarkers. In Borenstein AR and Mortimer JA. Alzheimer’s Disease: Life Course Perspectives on Risk Reduction. 2016; New York: Elsevier.
- Inouye SK, Van Dyck CH, Allessi EA, et al. Clarifying confusion: The confusion assessment method. Ann Int Med. 1990; 113: 941-948.
- Grover S, Kate N. Assessment scales for delirium: A review. World J Psychiatry. 2012; 2: 58-70.
- Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005; 53: 695-99.
- Wang HR, Woo YS, Bahk WM. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci. 2013; 67: 323-331.
- Hawkins SB, Bucklin M, Muzyk AJ. Quetiapine for the treatment of delirium. J Hosp Med. 2013; 8: 215-220.
- Mendioloa-Precoma J, Berumen LC, Padilla K, et al. Therapies for prevention and treatment of Alzheimer’s disease. Biomed Res Int. 2016; article ID 2589276: 1-16.
- Vemuri, P, Fields J, Peter J, et al. Cognitive interventions in Alzheimer’s and Parkinson’s diseases: Emerging mechanisms and role of imaging. Curr Opin Neurol. 2016; 29: 405-411.
- Woods B, Aquirre E, Spector AE, et al. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of System Rev. 2012; 2.
- Groot C, Hooghiemstra AM, Raijmakers PGHM, et al. The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials. Ageing Res Rev. 2016; 25: 13-23.
- Lamport DJ, Saunders C, Butler LT et al. Fruits, 100% juices, and cognitive function. Nutr Rev. 2014; 72: 774-789.
- Bolzetta F, Veronese N, De Rui M, et al. Are the recommended dietary allowances for vitamins appropriate for elderly people? J Acad Nutr Diet. 2015; 115:1789-1797.
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Original Version of the Topic
Deepthi S. Saxena, MD. Delirium and Dementia. 09/20/2013.
Diane Schretzman Mortimer, MD
Nothing to Disclose