Delirium Superimposed on Dementia in Perioperative Period and Intensive Care
Abstract
:1. Introduction
2. Pathophysiology of Dementia
3. Pathophysiology of Delirium
4. Delirium and Dementia—A Pathophysiological Interrelationship
5. Symptoms of Delirium
6. Types of Delirium
7. Diagnosis of Delirium Superimposed on Dementia
- Loneliness of the patient and absence of a person that would monitor the patient’s daily condition and who could notice a sudden change in behavior;
- Lack of doctor–patient communication;
- Misconception that older people are “withdrawn” and disorganized on their own;
- Misconception that a patient being asleep is only attributable to fatigue.
8. Dementia Management
8.1. Acetylcholinesterase Inhibitors
8.2. Memantine
9. Delirium Management
10. Summary
Author Contributions
Funding
Conflicts of Interest
References
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Vulnerability Factors | Precipitating Factors |
---|---|
Demographics male gender age ≥ 65 years old educational background | Severe illness infection, sepsis inadequate pain control trauma hypo- or hyperthermia |
Comorbidity dementia chronic kidney disease endstage liver disease terminal illness | CNS illness intracerebral hemorrhage cerebrovascular accident meningitis/encephalitis nonconvulsive status epilepticus cerebral edema tumor hydrocephalus |
Functional status immobility visual impairment hearing impairment | Metabolic disorder thiamine deficiency renal failure liver failure electrolyte imbalance hypo- or hyperglycemia thyroid dysfunction glucocorticoid therapy hypophysis disfunction porphyria |
Baseline medication usage polypharmacy baseline psychoactive medication and drug use * substance withdrawal | Cardiorespiratory acute coronary disease congestive cardiac failure hypoxemia hypercarbia shock hypertensive encephalopathy |
Malnutrition & dehydration | Mobility restriction use of physical restraints use of bladder catheters intubation assisted ventilation use of vascular catheters intermittent pneumatic compression orthopedic cast |
Depression | Other malignant hyperthermia serotonin syndrome malignant catatonia paraneoplastic syndrome >3 medications added anti-NMDA(N-methyl-d-aspartate) encephalitis any iatrogenic event drugs and medications taken |
Circadian rhythm disruption |
Feature | Delirium | Dementia |
---|---|---|
Onset | Sudden—hours/days | Insidious and slow |
Cause | Other medical emergency | Baseline CNS disease—neurodegenerative or other |
Course | Can be short if treated; usually reversible | Progressive—treatment slows the progression |
Attention | Impaired initially | Usually preserved; may be impaired in advanced stages |
Orientation | Impaired initially | Usually preserved; may be impaired in advanced stages |
Memory | Impaired initially; may be unable to recall the incident | Initially lost of short-term memory; degree of memory loss increases as the disease progresses |
Behaviour | Agitated/somnolent | Usually normal; may become agitated in advanced stages |
Perceptual Disturbances | Visual hallucinations; misperceptions; illusions | Hallucinations and misperceptions may occur mostly in DLB |
Feature | Hypoactive | Hyperactive |
---|---|---|
Arousal | Decreased arousal and alertness; somnolence; reduced awareness | Hypervigilant; easily startled; distractable |
Mood | Depressed, irritable; mood swings; patient is disinhibited | Labile: from comative to euphoric |
Psychomotor activity | Slow, quiet, withdrawn | Restless, agitated, combative, irritable |
Past psychiatric history | May have experienced delirium before | Correlated with alcohol or drug withdrawal; may have experienced delirium before |
Circadian rythm | Increased daytime sleepiness | Prominent disturbances; nightmares and night terrors |
Disease | Diagnostic Method | |
---|---|---|
CNS | stroke, trauma brain injury, subsclerotic haemorrhage | CT/MRI |
Non-convulsive status epilepsy, partial epileptic seizure with cognitive decline | EEG | |
Cardiovascular System | Acute coronary syndrome | ECG, Troponin, CK-MB |
Atrial fibrillation | ECG | |
Abdominal aortic aneurysm | Abdominal ultrasound, CT, MRI | |
Respiratory System | Pulmonary embolism | CT, angiography of pulmonary vessels, ventilation/perfusion scintigraphy |
Pulmonary oedema | Chest radiograph | |
Metabolic Disturbances | Hypermetabolic crisis, myxoedema | TSH, fT4 |
Diabetes mellitus—keto alkalosis Hyperosmolar Hyperglycaemic Nonketotic Syndrome (HHNS) | Glycaemia measurement | |
Acid-Base balance disturbances | Arterial blood gas | |
Electrolyte balance disturbances; dehydration | Plasma electrolytes measurement | |
Hematologic Disturbances | Acute blood loss | Blood morphology evaluation |
Medication | benzodiazepines, antipsychotics, opioids, sedation drugs, anticholinergic drugs | Drug level in blood/urine |
Other | Sleep deprivation, psychosis, depression | Psychiatric evaluation |
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Krzych, Ł.J.; Rachfalska, N.; Putowski, Z. Delirium Superimposed on Dementia in Perioperative Period and Intensive Care. J. Clin. Med. 2020, 9, 3279. https://doi.org/10.3390/jcm9103279
Krzych ŁJ, Rachfalska N, Putowski Z. Delirium Superimposed on Dementia in Perioperative Period and Intensive Care. Journal of Clinical Medicine. 2020; 9(10):3279. https://doi.org/10.3390/jcm9103279
Chicago/Turabian StyleKrzych, Łukasz J., Natalia Rachfalska, and Zbigniew Putowski. 2020. "Delirium Superimposed on Dementia in Perioperative Period and Intensive Care" Journal of Clinical Medicine 9, no. 10: 3279. https://doi.org/10.3390/jcm9103279