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Dementia, Emergency Medicine

Basics

Description

- Variable hereditary - Increased risk of Alzheimer disease in 1st-degree relatives of patients with Alzheimer - Apolipoprotein Оµ4 is the only well-established mutation with late-onset Alzheimer

- Insidious onset, with initial complaints of anxiety, depression, frustration, increased forgetfulness - Generally preceded by "mild cognitive impairment,"пїЅ an intermediate state of cognitive function between normal aging and those meeting criteria for dementia - Can be grouped into 3 categories: - Early: Difficulty concentrating, memory deficits, difficulty with complex tasks, social withdrawal - Moderate: Major memory difficulties, need assistance with activities of daily living - Severe: Minimal ability to speak or communicate, difficulty eating, loss of psychomotor skills

- Head-to-toe evaluation, all organ systems - Meticulous neurologic exam: - Mental status evaluation - Cranial nerves - Reflexes - Motor, sensory, cerebellar, gait

- Must eliminate acute reversible or exacerbating factors - Extent of workup is related to history and course of illness: - Extensive evaluation for new diagnosis - Directed evaluation for sudden change of dementia - Limited evaluation for stable disease previously assessed

- Extent of evaluation dependent on patient condition and suspected cause - New diagnosis or sudden deterioration: - CBC - ESR/CRP - CMP - Ammonia - Urinalysis - Toxicology screen - Thyroid-stimulating hormone - Vitamin B12 level - Syphilis serology (RPR) - HIV - Blood cultures if fever present - Urine cultures if fever present - Antinuclear antibody if SLE suspected

- New diagnosis or sudden deterioration in established dementia: - CXR if infection considered - Head CT, without and with contrast - EEG if suspicion of seizure disorder - Brain MRI/MRA in selected cases - More advanced imaging (PET, etc.) should be reserved for use by specialists

- Obtain history from friends, family - Provide for patient and staff safety - Manage agitation - Attentiveness to comorbid conditions - Treat acute toxic and metabolic disorders: - Hypoglycemia - Hypothermia - Hyperthermia

- Must determine if patient presents with acute change in mental status - Consider full differential diagnosis-evaluate and treat appropriately: - Treat hypoglycemia with PO or IV dextrose. - Treat narcotic overdose or excess with naloxone. - Rewarm if hypothermic. - Antipyretic for hyperthermia - IV fluids for dehydration - Correct electrolyte abnormalities - Administer antibiotics for infection: - UTI and pneumonia most common occult infections; look for wounds and decubitus ulcers

- Treat seizures: - Lorazepam, other agents as needed - Long-term management in conjunction with neurology

- Soft restraints if chemical sedation ineffective - Attempt to limit number of medications: - Reduced likelihood of toxicity - Reduced likelihood of drug-drug interaction - If agitation not an issue, eliminate all sedative-hypnotics

- Alzheimers agents: Always start at lowest dose: - Donepezil: 5-10 mg PO at bedtime - Rivastigmine: 1.5-6 mg PO BID - Galantamine: 4-12 mg PO BID - Above 3 anticholinergics without clear superior agent, watch for side effects including nausea, vomiting, diarrhea - Consider memantine (NMDA receptor antagonist) in those with poor response to anticholinergics: 5 mg PO QID-10 mg PO BID - Effects generally modest, best started, and changed by primary provider - Numerous trials showing inconsistent or negative benefit of anti-inflammatory agents, estrogens, and statins for Alzheimer

- Antidepressants: Start with lowest dose: - Oversedation a problem - May worsen dementia - Useful in patients who cannot sleep

  • Progressive deterioration in cognition, behavior, or both without impaired consciousness that is severe enough to interfere with activities of daily living due to alteration in cortical brain function. A chronic and progressive form of organic brain syndrome.
  • Over 50 different causes, but >60% caused by Alzheimer diseaseInvolves increased neurofibrillary tangles and elevated beta amyloid plaques
  • Prevalence 1% at age 60 yr to 30-50% by age 85 yr
  • Characterized by gradual decline in cognitive functioning:Generally evolves over period of yearsCourse is highly variable, months to years in durationRapid decline indicative of other causes, or rare rapid onset causes of dementia (prion diseases, progressive supranuclear palsy)
  • Variable hereditaryIncreased risk of Alzheimer disease in 1st-degree relatives of patients with AlzheimerApolipoprotein Оµ4 is the only well-established mutation with late-onset Alzheimer

Etiology

  • Primary dementia:Cortical (Alzheimer disease, frontotemporal dementia)Subcortical (Huntington disease, Parkinson disease, progressive supranuclear palsy)
  • Secondary dementia:Cerebrovascular disease (multi-infarct dementia)Toxic, metabolic, nutritional derangementsPrion disorders (Creutzfelt-Jakob or bovine spongiform encephalopathy and variants)Infectious agents (HIV, syphilis, encephalitis)Vasculitis (systemic lupus erythematosus, thrombotic thrombocytopenic purpura)Traumatic (chronic subdural hematomas, pugilistic dementia)Structural (normal pressure hydrocephalus, brain masses)Binswanger disease
  • Reversible (~15%) causes include normal pressure hydrocephalus, medications, intracranial masses, and alcohol abuse syndromes
  • Pseudodementia:Depression in elderly can present with dementia-like symptomsCommon in mildly demented patients, look for pin-point event with short duration of symptomsGenerally with history of psychiatric conditions, emphasis on failures and disabilities

Diagnosis

Signs and Symptoms

  • Insidious onset, with initial complaints of anxiety, depression, frustration, increased forgetfulness
  • Generally preceded by "mild cognitive impairment,"пїЅ an intermediate state of cognitive function between normal aging and those meeting criteria for dementia
  • Can be grouped into 3 categories:Early: Difficulty concentrating, memory deficits, difficulty with complex tasks, social withdrawalModerate: Major memory difficulties, need assistance with activities of daily livingSevere: Minimal ability to speak or communicate, difficulty eating, loss of psychomotor skills
  • Diagnostic criteria (from American Psychiatric Association):Development of multiple cognitive deficits manifested by both:Memory impairmentOne (or more) of the following cognitive disturbances: Aphasia, apraxia, agnosia, disturbance in executive functioningCognitive deficits that cause significant impairment in social or occupational functioning and are a decline from prior levels of functioningDeficits do not occur during course of delirium

History

  • Must include input from family and friends
  • Complete list of medications
  • Comorbid diseases
  • Prior history of similar behavior
  • Onset and progression
  • Consider use of Montreal Cognitive Assessment, Short Test of Mental Status (alternative to mini-mental status exam)

Physical Exam

Full and complete physical exam: пїЅ

  • Head-to-toe evaluation, all organ systems
  • Meticulous neurologic exam:Mental status evaluationCranial nervesReflexesMotor, sensory, cerebellar, gait

Essential Workup

  • Must eliminate acute reversible or exacerbating factors
  • Extent of workup is related to history and course of illness:Extensive evaluation for new diagnosisDirected evaluation for sudden change of dementiaLimited evaluation for stable disease previously assessed
  • Must be able to identify signs and symptoms of the reversible causes of dementia

Diagnosis Tests & Interpretation

Lab

  • Extent of evaluation dependent on patient condition and suspected cause
  • New diagnosis or sudden deterioration:CBCESR/CRPCMPAmmoniaUrinalysisToxicology screenThyroid-stimulating hormoneVitamin B12 levelSyphilis serology (RPR)HIVBlood cultures if fever presentUrine cultures if fever presentAntinuclear antibody if SLE suspected
  • Established diagnosis with stable disease: No tests may be required.

Imaging

  • New diagnosis or sudden deterioration in established dementia:CXR if infection consideredHead CT, without and with contrastEEG if suspicion of seizure disorderBrain MRI/MRA in selected casesMore advanced imaging (PET, etc.) should be reserved for use by specialists
  • Established diagnosis with stable disease: Studies may not be required.

Diagnostic Procedures/Surgery

  • Lumbar puncture and CSF analysis, syphilis serology
  • EEG if seizure suspected

Differential Diagnosis

  • Toxic, metabolic, nutritional abnormalities:Narcotics, sedatives, hypnoticsAlcoholHeavy metalsDehydrationElectrolyte abnormalities
  • Pseudodementia
  • Delirium (high suspicion for UTI and pneumonia in febrile patients)
  • Senescent aging

Treatment

Pre-Hospital

  • Obtain history from friends, family
  • Provide for patient and staff safety
  • Manage agitation
  • Attentiveness to comorbid conditions
  • Treat acute toxic and metabolic disorders:HypoglycemiaHypothermiaHyperthermia

Initial Stabilization/Therapy

  • Ensure adequate airway
  • Administer O2 if hypoxic
  • Ensure normal vital signs
  • Establish IV access if required
  • In agitated patients, provide for patient and staff safety

Ed Treatment/Procedures

  • Must determine if patient presents with acute change in mental status
  • Consider full differential diagnosis-evaluate and treat appropriately:Treat hypoglycemia with PO or IV dextrose.Treat narcotic overdose or excess with naloxone.Rewarm if hypothermic.Antipyretic for hyperthermiaIV fluids for dehydrationCorrect electrolyte abnormalitiesAdminister antibiotics for infection:UTI and pneumonia most common occult infections; look for wounds and decubitus ulcersTreat seizures:Lorazepam, other agents as neededLong-term management in conjunction with neurology
  • Sedation for agitation:Start with low doses and increase as necessary to achieve clinical result.Neuroleptics: Haloperidol, risperidone, ziprasidoneBenzodiazepines: Lorazepam, midazolam
  • Soft restraints if chemical sedation ineffective
  • Attempt to limit number of medications:Reduced likelihood of toxicityReduced likelihood of drug-drug interactionIf agitation not an issue, eliminate all sedative-hypnotics
  • Treat depression

Medication

  • Alzheimers agents: Always start at lowest dose:Donepezil: 5-10 mg PO at bedtimeRivastigmine: 1.5-6 mg PO BIDGalantamine: 4-12 mg PO BIDAbove 3 anticholinergics without clear superior agent, watch for side effects including nausea, vomiting, diarrheaConsider memantine (NMDA receptor antagonist) in those with poor response to anticholinergics: 5 mg PO QID-10 mg PO BIDEffects generally modest, best started, and changed by primary providerNumerous trials showing inconsistent or negative benefit of anti-inflammatory agents, estrogens, and statins for Alzheimer
  • Antidepressants: Start with lowest dose:Oversedation a problemMay worsen dementiaUseful in patients who cannot sleep
  • Sedative agents: Always start with lowest doseDroperidol: 0.625-2.5 mg IV-advantage, rapid onset; disadvantage, risk for QT prolongation
  • Haloperidol: 0.5-2 mg PO BID; start with lowest dose 0.5-2.5 mg IM or IV if rapid onset required
  • Lorazepam: 0.5-1 mg IV, 0.5-2 mg PO
  • Midazolam: 0.5-2 mg IV slow push
  • Naloxone: 0.4-2 mg IVP
  • Risperidone: 0.5-2 mg PO BID; start with lowest dose
  • Ziprasidone: 20-80 mg PO BID, 10-20 mg IM q4h; start with lowest dose

Follow-Up

Disposition

Admission Criteria

  • Unstable vital signs
  • Significant comorbid condition requiring parenteral medications:PneumoniaUTIFluid and electrolyte disorder
  • Uncertain diagnosis requiring evaluation and management that is not suitable for outpatients
  • Inadequate home support coupled with inability to arrange suitable placement from ED

Discharge Criteria

  • Stable vital signs
  • No significant unstable comorbid conditions
  • Secure diagnosis or elimination of life-threatening organic disease
  • Adequate home support, watch for caregiver burnout
  • Reliable access to follow-up care

Issues for Referral

  • Patients may need assistance with transportation, finances, etc.
  • Patients with other comorbidities need referral to appropriate specialists.

Follow-Up Recommendations

  • Primary care
  • Geriatrician
  • Psychiatrist
  • Neurologist

Pearls and Pitfalls

  • Primary dementia is characterized by slow, steady progression:Course is generally 5-10 yr from diagnosis to death.
  • Can fluctuate as consequence of intervening illness and comorbid conditions
  • Cholinesterase medications can improve functional status in patients with Alzheimer disease.
  • Careful attention to medications, secondary illnesses, and prompt intervention for infections can improve quality of life and longevity.
  • Death is generally consequence of infection, cardiovascular disease, or injury.

Additional Reading

  • Holsinger пїЅT, Deveau пїЅJ, Boustani пїЅM, et al. Does this patient have dementia? JAMA. 2007;297:2391-2404.
  • Langa пїЅKM, Foster пїЅNL, Larson пїЅEB. Mixed dementia: Emerging concepts and therapeutic implications. JAMA. 2004;292:2901-2908.
  • Mayeux, пїЅR. Clinical practice. Early Alzheimers disease. N Engl J Med. 2010;362:2194-2201.
  • Mitchell пїЅSL, Teno пїЅJM, Kiely пїЅDK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361:1529-1538.
  • Petersen пїЅRC. Mild cognitive impairment. N Engl J Med. 2011;364:2227-2234.
  • Savva пїЅGM, Wharton пїЅSB, Ince пїЅPG, et al. Age, neuropathology, and dementia. N Engl J Med. 2009;360:2302-2309.

See Also (Topic, Algorithm, Electronic Media Element)

  • Altered Mental Status
  • Delirium

Codes

ICD9

  • 294.10 Dementia in conditions classified elsewhere without behavioral disturbance
  • 294.20 Dementia, unspecified, without behavioral disturbance
  • 331.0 Alzheimers disease
  • 294.21 Dementia, unspecified, with behavioral disturbance
  • 290.40 Vascular dementia, uncomplicated
  • 290.41 Vascular dementia, with delirium
  • 290.42 Vascular dementia, with delusions
  • 290.43 Vascular dementia, with depressed mood
  • 290.4 Vascular dementia
  • 294.11 Dementia in conditions classified elsewhere with behavioral disturbance
  • 294.1 Dementia in conditions classified elsewhere
  • 294.2 Dementia, unspecified

ICD10

  • F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
  • F03.90 Unspecified dementia without behavioral disturbance
  • G30.9 Alzheimers disease, unspecified
  • F03.91 Unspecified dementia with behavioral disturbance
  • F01.50 Vascular dementia without behavioral disturbance
  • F01.51 Vascular dementia with behavioral disturbance
  • F01.5 Vascular dementia
  • F02.81 Dementia in oth diseases classd elswhr w behavioral disturb
  • F03.9 Unspecified dementia
  • F03 Unspecified dementia

SNOMED

  • 52448006 Dementia (disorder)
  • 1581000119101 Dementia of the Alzheimer type with behavioral disturbance (disorder)
  • 191519005 Dementia associated with another disease (disorder)
  • 1591000119103 Dementia with behavioral disturbance (disorder)
  • 10349009 Multi-infarct dementia with delirium (disorder)
  • 14070001 Multi-infarct dementia with depression (disorder)
  • 25772007 Multi-infarct dementia with delusions (disorder)
  • 56267009 Multi-infarct dementia (disorder)
  • 70936005 Multi-infarct dementia, uncomplicated (disorder)