Discussion around confusion and dementia by Philip Hall Dementia Nurse at Heart of England NHS Trust

1. Phillip Hall – Senior Nurse Dementia
Phillip.hall@heartofengland.nhs.uk
Ext - 44210

2.  a mental state characterized by disorientation
regarding time, place, person, or situation. It
causes bewilderment, perplexity, lack of
orderly thought, and inability to choose or act
decisively and perform the activities of daily
living

3. Confusion in the acute hospital

4.  Dementia – some causes treatable
 Delirium – usually treatable and often the
first symptom of serious underlying
condition
 Depression – often responds well to
treatment
 All benefit from adaptations to care

5.  The development of multiple cognitive deficits manifested by:
 A. Two or more of the following cognitive disturbances:
 (a) aphasia (language disturbance)
 (b) apraxia (impaired ability to carry out motor activities depite intact motor function)
 (c) agnosia (failure to recognize or identify objects despite intact sensory function)
 (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
 (e) memory impairment (impaired ability to learn new information or to recall previously
learned information)
 B. The cognitive deficits in criteria A each cause significant impairment in social or occupational functioning and
represent a significant decline from a previous level of functioning.
 C. The course is characterized by gradual onset and continuing cognitive decline

6.  Alzheimer’s Disease - 30% to 50%
 Vascular Dementia - 20% (but 50% of cases in
hospital)
 Lewy Body Dementia – 10% to 30%
 Frontal Lobe Dementia – 5%
 Other causes - <5%

7.  Attention
 Concentration
 Orientation
 Short term memory
 Long term memory
 Praxis
 Language
 Executive function

9.  Delirium is a syndrome, or group of
symptoms, caused by a disturbance in the
normal functioning of the brain. The delirious
patient has a reduced awareness of and
responsiveness to the environment, which
may be manifested as disorientation,
incoherence, and memory disturbance.
Delirium is often marked by hallucinations,
delusions, and a dream-like state.

10. CONFUSION ASSESSMENT METHOD (CAM) SHORTENED VERSION WORKSHEET
 I. ACUTE ONSET AND FLUCTUATING COURSE BOX 1
a) Is there evidence of an acute change in mental status from the patient’s baseline? No ____ Yes___
b) Did the (abnormal) behaviour fluctuate during the day, that is tend to come and go or increase and
decrease in severity? No ____ Yes___
 II. INATTENTION
Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty
keeping track of what was being said? No ____ Yes___
________________________________________________________________________
 III. DISORGANIZED THINKING BOX 2
Was the patient ‘s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear
or illogical flow of ideas, or unpredictable switching from subject to subject? No ____ Yes____
 IV. ALTERED LEVEL OF CONSCIOUSNESS
Overall, how would you rate the patient’s level of consciousness?
Alert (normal) or
___ Vigilant (hyperalert)
___ Lethargic (drowsy, easily aroused)
___ Stupor (difficult to arouse)
___ Coma (unarousable)
Do any checks appear? (any level of consciousness other than ‘normal’) No ____ Yes ___
________________________________________________________________________
If all ‘Yes’s’ in Box 1 are checked and at least one ‘Yes’ in Box 2 is checked a diagnosis of delirium is suggested.

11.  Deteriorating cognitive function: reduced
concentration, slow responses, confusion
 Perception: visual or auditory hallucinations
 Physical function: reduced mobility/
movement, restlessness, agitation, change in
appetite, sleep disturbances
 Social behaviour: lack of co-operation,
withdrawal, altered communication, mood
 Emotional disturbance: mood swings

12. Three types of delirium;
Hyperactive:
 Agitated, calling out, restless, wandering
 Least common, most frequently diagnosed
 Increased risk of falls and injury
Hypoactive:
 Lethargic, slow to answer questions
 Most common, most dangerous, least recognised
 Increased pressure ulcer risk and aspirational pneumonia
Mixed: combination of the above

13.  Increased morbidity
 Increased mortality
 Increased falls
 Higher length of stay
 Decreased likelihood of return home
 Eight fold increase of new diagnosis of
dementia
 Longer the delirium remains untreated the
greater all of the above risks

14. CHARACTERISTI
CS
DEMENTIA DELIRIUM DEPRESSION
Onset Insidious, slow and often
unrecognized
Sudden, abrupt Recent, may correspond
with life change
Course over 24
hours
Fairly stable, may see
changes due to stresses
Fluctuating, often with
nighttime exacerbations
Fairly stable, may be
worse in the morning
Consciousness Clear Reduced Clear
Alertness Normal Increased, decreased or
variable
Normal
Psychomotor
activity
Normal but may have
apraxia
Increased, decreased,
mixed
Variable, agitation or
retardation
Duration Months to years Hours to weeks Variable (at least 6
weeks) may be months to
years
Attention Generally normal Globally disordered,
fluctuates
Little impairment, very
distractible
Orientation Often impaired (answer
may be close to right)
Usually impaired,
variable, fluctuates
Usually normal, may
answer “don’t know”
Speech Difficulty word finding,
preseveration
Often incoherent, slow
or rapid
May be slow

15.  Right place, right time, right approach
 History is essential (recent and longer term)
 Confusion isn’t restricted to a single cause, at
least 5 out of 6 patients with delirium will
already have dementia
 Communication difficulties will need serious
consideration
 Be aware of impact of identifying a problem
 Refer (RAID)

16.  Alzheimer’s Society –
http://www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200
293
Other cognitive assessments;
 Addenbrooke’s Cognitive Assessment -
http://www.stvincents.ie/dynamic/File/Addenbrookes_A_SVUH_MedEl_tool.p
df
 6 Item Cognitive Test –
http://www.patient.co.uk/doctor/six-item-cognitive-impairment-test-6cit
 MMSE –
http://www.guysandstthomas.nhs.uk/resources/our-services/acute-
medicine-gi-surgery/elderly-care/mini-mental-state-evaluation.pdf

17.  Confusion Assessment Method training manual -
http://www.viha.ca/NR/rdonlyres/0AC07A64-FF24-41E3-BDC5-
41CFE4E44F33/0/cam_training_pkg.pdf
 European Delirium association –
http://www.europeandeliriumassociation.com/

18. Differential diagnosis – dementia and depression;
http://www.cmglinks.com/cmg/lectures_dementia/part1/006.htm
Depression in older adults (RCP);
http://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthproblems/depression/depressioninol
deradults.aspx
Depression rating scales;
Geriatric Depression Scale –
http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF
Cornell Scale For Depression In Dementia –
http://geropsychiatriceducation.vch.ca/docs/edu-downloads/depression/cornell_scale_depression.pdf