Mental changes are one of the primary reasons individuals have to move out of their homes. We worry about it and watch for it in ourselves and loved ones. Those changes can happen suddenly, or occur slowly over a period of time. Many think it is simply a normal part of getting older: “What can you expect; she is (age)?"
Actually no – it is not a normal part of aging. 50% to 70% over the age of 85 are not bothered with dementia. Every age is at risk for delirium if the conditions are right.
Delirium – generally a sudden change in orientation, memory, mood or abilities that occurs over hours or days and may fluctuate. Underlying cause is generally medications/drugs, metabolic imbalance, change in medical condition, surgical intervention or neurological change. Delirium is often reversible if caught in time.
Dementia - mental and memory changes occur over a period of time. Nearly 40 conditions are related to dementia with a small number being reversible.
The likelihood of having diseases and conditions related to dementia increases with age. A person with dementia is more susceptible to delirium. Changes that do not follow normal progression of a diagnosis should be evaluated. Untreated delirium may become dementia or increase the severity of dementia.
The discussion below will cover common causes of delirium and reversible dementia.
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We are going to review delirium, delirium with dementia, reversible dementia, untreated delirium morphing into permanent dementia and dementia with a delirious episode. Where to draw the line for a diagnosis between delirium (a sudden change in mental status), dementia (long term change in mental status) and an acute episode of a mental illness is difficult. Adding to the confusion, the “line of definition” has changed over time and will change again, so when discussing it with health professionals or support team everyone may have a slightly different understanding.
By the end of this diary, we should be aware of these facts:
1. There are many reasons mental changes happen.
2. A change in mental status may express itself as behavior change.
3. A person with mental changes can have multiple factors contributing to the mental change.
4. Whenever a mental change happens it should be evaluated for underlying causes.
5. Any underlying cause that is treatable should be treated. If not, a temporary problem may become a permanent change in mental status.
6. Any underlying cause that is removable should be removed or discontinued. If not, a temporary problem may become a permanent change in mental status.
7. When someone is physically or mentally fragile they are more susceptible to delirium.
REVERSIBLE DEMENTIA
Mental changes associated with reversible dementias may be modified by treating the underlying cause. One common metabolic problem is low thyroid hormone or hypothyroidism. Some common nutritional causes are low dietary niacin and problems with vitamin B 12 absorption. Depression can sometimes cause dementia symptoms that improve with antidepressants. Certain long-term infections can cause dementia symptoms.
DELIRIUM
Signs & Symptoms
Delirium presents itself as a sudden change in someone's normal pattern of mental function and/or behavior. It should be considered for unusual or new anxiety, fearfulness, pacing, hallucinations, agitation, confusion or hallucinations. Some individuals will become quieter or appear spaced out.
In a person with dementia, their normal symptoms of dementia may be more exaggerated or fluctuate more rapidly when they are having problems with delirium. They may be more confused than normal, have more exaggerated agitation, or be extremely quiet.
Identifying delirium is not always easy and it may be mistaken for episodic fluctuations of a mental illness.
What to do
Avoid as many of the causes as possible. Some causes are unavoidable, but you may be able to have a plan of action to mitigate their effects. For example, you can keep quick carbohydrates and protein available to eat for low blood sugar management.
If you notice the signs and symptoms of delirium, seek medical attention. Medical intervention will be required to determine and treat many sources of delirium. You have two problems. First, you have to get a delirious person to the doctor or hospital. Second, the medical practitioner really needs to identify the underlying causes and not just treat the symptoms.
Common Causes of delirium
Medications/Drugs
I group medications, alcohol, illegal drugs, and dietary supplements together since they all are used as a chemical intervention for the body. The problem can be a side effect, sudden withdrawal, overdose, over treating a condition, drug interaction or drug-disease interaction.
Drugs that have anticholinergic activity are often implicated in causing delirium. Regular use may also increase the risk for developing dementia in the future. Anticholinergics block the neurotransmitter acetylcholine, it has a wide range of activity and affects every organ system in the body.
It is not uncommon for someone to be taking multiple prescription and over-the-counter (OTC) meds with various anticholinergic activity. The anticholinergic activity from the each of medications are cumulative and and create an "anticolinergic burden". One of the stronger OTC meds is dephenhydramine (Benadryl), an antihistamine. It is a common ingredient in OTC sleeping pills, allergy/cold combinations, and analgesic combinations. I have seen a number of individuals who had been diagnosed with dementia regain mental clarity after the diphenydramine was stopped.
The Beers Criteria is a useful list of medications most likely to cause problems in individuals over the age of 65 due to increased sensitivity to adverse reactions and age related changes in liver and kidney function. It includes a fairly comprehensive list of anticholinergic drugs in Table 8. Any person over 65 or with kidney (renal) impairment and liver (hepatic) impairment (not related to age) should have their medications compared to this list. Their doctor should be consulted about discontinuing or replacing meds that are identified as a potential problem in the Beers Criteria.
Over treating a medical condition beyond target goals can result in delirium. For example, a person with diabetes may start an exercise routine and modify their diet. Now their medication dosage is higher than they need to control diabetes and low blood sugars begin to effect their mental function. Similar issues can occur with high blood pressure (hypertensive) medications: doses/drugs may need to be adjusted due to lifestyle modification that lower blood pressure.
Medication overdoses can easily occur due to a drug to drug interaction (adding or removing a drug) and by not adjusting dosing guidelines to accommodate metabolic impairment. Medications that one has taken for years can start to cause a problem when normal aging affects the efficiency of drug metabolism.
Another overdose risk factor is when someone begins to have assistance in remembering to take medication doses. A medication that had been taken erratically is now taken regularly as prescribed, resulting in a higher daily dose. The other problem can be a patient self treating in addition to medication assistance. My grandmother had a stash of Parkinson’s meds I was unaware of and she would take them in addition to the ones the caregivers were supplying. I did not figure it out until the EMT was questioning her and having her describe the hallucinations.
Antibiotics and antifungals can cause a quick die off of bacteria or fungal targets. If the bacteria or fungus (yeast) are a type that release toxins it may affect mental function.
Physical Illness or Injury
The first sign of an infection may be delirium. A white blood cell count or urine sample can help identify the problem.
Pain perception changes as a person ages and may be expressed as anger, agitation, confusion, or anxiety. When questioned about pain, the person may say they do not hurt. Both acute and chronic pain can present as mental and behavioral changes rather than feeling pain.
Fracture, bad sprain or heart attack may not be identified with complaints of pain, but rather expressed as delirium.
Electrolyte imbalances leading to delirium can be brought on by nutrition, medications, diarrhea, vomiting, and hydration status.
Surgery
Postoperative delirium is the most common complication of surgery in the elderly. Additional care giving may be necessary. There is also an increased risk of dementia and cognitive decline with general anesthesia.
Environmental
Stress caused by the change of a room, roommates, caregiver, or living arrangements can be contributing factors to delirium. It takes time to re-orientate. Having a few familiar items, sounds (music) or pictures can assist in the process of re-orienting to changes.
Sensory deficiencies may be isolating, causing an increased likelihood of delirium. Make sure hearing aids, glasses and dentures are available.
Studentofearth has experienced health issues from three perspectives: pharmacist, caregiver, and patient. As a pharmacist, she was involved in a variety of practice settings: long-term care consulting and dispensing, compounding, retail and rural hospital. She ultimately focused on medication management to maximize benefits and minimize harmful effects. Over the years, she has been the caregiver or coordinator for elder family members, retiring early to care for her father. Studentofearth’s personal experience with the daily consequences of chronic illness comes from having fibromyalgia for the past 23 years. Since her father’s death, she no longer is mentally and physically exhausted from her caregiving, and is contemplating what she wishes to do next.
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