PERT Program

Tip of the Month: April 2005


BEHAVIORAL SYMPTOMS IN COGNITIVE DISORDERS


This article is the first of a two-part series. Part I will define confusion, differentiate delirium and dementia, and identify common behavioral symptoms that occur in delirium and dementia. Part II will review specific treatment strategies for the behavioral symptoms that occur in delirium and dementia.


Health professionals often care for people who have cognitive deficits. Cognitive functions include orientation, short-term and long-term memory, language, calculation, abstraction, insight, and judgment. In addition, the ability to identify objects and their functions and to perform simple or complex tasks involves cognitive functions. Unfortunately, in the case of older adults these cognitive deficits are sometimes considered to be a normal part of aging rather than a pathologic state.


Defining Confusion

The language that health professionals use to describe cognitive deficits often is not specific. People with deficits in discrete areas of cognition are categorized using global descriptors, such as confused or agitated, which fail to identify the specific areas of cognition affected. Although many factors (e.g., medical comorbidities, education) make longitudinal testing among older adults difficult, research has shown that intellectual declines are often a function of psychomotor slowing and loss of sensory-perceptual abilities and not a loss of cognitive functions.1 Thus, when treating any person with a cognitive deficit, health-care professionals must identify the type of confusional state (delirium or dementia) because treatment varies for each type.


Delirium

Delirium is an acute neurological disturbance characterized by rapid onset, fluctuating levels of consciousness, and impairments in cognition or perception.2 People who develop delirium may have had no previous cognitive deficits or they may have preexisting cognitive deficits from a chronic dementing disorder such as Alzheimer's disease.

The most common causes of delirium are acute medical events, including medication toxicities. Exact prevalence figures for delirium are difficult to determine because estimates vary widely according to the population studied. For instance, a review of people with postoperative delirium cited rates of 0 to 73.5%.3 Breitbart and Strout4 found that over 80% of people with terminal illness developed delirium in the last weeks of life. Lawlor and colleagues5 found that among persons with advanced cancer, delirium was reversible in 50% of the cases. Breitbart et al.6 reported a 30 to 40% prevalence of delirium among hospitalized AIDS patients. An estimated 22% of community-dwelling people with Alzheimer's disease experience episodes of delirium during the course of their illness.7 Regardless of the cause of the delirium, patients with delirium are at increased risk for morbidity (e.g., falls, pressure ulcers, or dehydration) and mortality.

Various subtypes of delirium have been identified:8-10
  1. Hyperactive delirium. Characterized by increased psychomotor activity, hypervigilance, delusions, irritability, combativeness, wandering, distractibility, or restlessness.

  2. Hypoactive delirium. Characterized by decreased activity, decreased alertness, lethargy, staring into space, apathy, or increased sleep.

  3. Mixed motor delirium. Presenting characteristics of both hyperactive and hypoactive delirium.

Each of these delirium subtypes poses significant risks. People with the hyperactive type are at increased risk for falls or may try to remove things like bandages or intravenous lines. People with the hypoactive subtype are at increased risk for pressure ulcers or aspiration pneumonia. Additionally, people with hypoactive delirium may not have their delirium identified as quickly as people with hyperactive delirium.


Dementia

Dementia is an irreversible neurologic disorder with multiple areas of cognitive deficits, manifested by memory impairment and at least one of the following: aphasia (difficulties with language), apraxia (difficulties with tasks), agnosia (difficulties in recognizing objects), or a disturbance in executive functioning (interrelated abilities that includes cognitive flexibility, concept formation, and self-monitoring). There are multiple types of dementia, each with different presenting symptoms, illness trajectories, and treatments. Because treatments and prognoses vary, accurate and timely diagnosis is critical. The following table describes the various types of dementia.

Types of Dementia*
Type of Dementia Symptoms Treatment
Alzheimer's disease (AD) Insidious onset with memory problems typically present. Personality changes also occur early, and cognitive deficits increase as the disease progresses. AD is the most common type of dementia. Anticholinesterase inhibitors (e.g., Aricept) to increase the intrasynaptic acetylcholine.

NMDA inhibitors (e.g., Memantine).
Vascular dementia Characterized by stepwise progression of patchy cognitive deterioration, focal neurologic signs, and symptoms or evidence of areas of cerebral infarct.

Relatively uncommon type of dementia. 		Treat the underlying cardiovascular condition.
Mixed dementia Progressive cognitive decline with both the neuropathological findings of cerebral infarcts and the symptomotology of AD. Anticholinesterase inhibitors.
Dementia with Lewy bodies (DLB) Fluctuating cognitive function, visual hallucinations, and Parkinsonism-like bradykinesia are symptoms prominent in the early stage. Anticholinesterase inhibitors.

Care should be taken in prescribing antipsychotics, due to marked sensitivity to the extrapyramidal symptoms associated with DLB.
Frontotemporal dementia (FTD)

[includes Pick's disease, frontal lobe degeneration of non-AD type, amyotrophic sclerosis with frontal lobe degeneration, and corticobasal degeneration] 		Presents with symptoms of frontal lobe dysfunction, such as impaired judgment, perseveration, impulsivity, socially inappropriate behavior, and executive dysfunction.

Later, memory and speech are affected and full dementia ensues. 		The marked cholinergic deficit of AD does not seem to occur in Pick's disease; however, differentiating it from AD is clinically difficult.
Dementia due to normal pressure hydrocephalus Symptoms include dementia, gait disturbance, and urinary incontinence, with dilatation of the cerebral ventricles. Surgical implantation of a cerebroventricular shunt.
Dementia in Parkinson's disease (PD) Symptoms include impaired memory and slowness of thinking. In addition, the motor symptoms of PD progress with the disease. Stage-specific treatmentof PD.
*Adapted from Raskind, Bonner, & Peskind.11


Other, less common types of dementia exist, such as dementia due to Huntington's disease or Creutzfelt-Jakob disease. The etiologies, symptoms, and treatments of these forms of dementia also vary.


Behavioral Symptoms Related to Delirium or Dementia

People with cognitive deficits associated with delirium or dementia may display one or more behavioral symptoms. These behavioral symptoms include Each of these behavioral symptoms responds to myriad nonpharmacologic or pharmacologic strategies. Part II of this article will review in depth these behavioral symptoms and successful treatment strategies.


Dr. Mary Shelkey, PhD, ARNP, Geriatric Specialist, and Director, RN Clinical Research Unit of Benaroya Research Institute, Virginia Mason Medical Center, Seattle, WA, provided this month's Tip. Dr. Shelkey also is Assistant Professor at the Seattle University School of Nursing.



References

  1. Wetherell, J.L., Reynolds, C.A., Gatz, M., & Pederson, N.L. (2002). Anxiety, cultural performance and cognitive decline in normal aging. Journal of Gerontological B: Psychology Sciences, Social Sciences, 57, P246-P255.
  2. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders. (4th ed.). Washington, D.C.: American Psychiatric Press.
  3. Van der Mast (1999). Postoperative delirium. Dementia Geriatric and Cognitive Disorders, 10, 401-405.
  4. Breitbart, W., & Strout, D. (2000). Delirium in the terminally ill. Clinics in Geriatric Medicine, 16(2), 357-372.
  5. Lawlor, P.G., Gagnon, B., Mancini, I.L. Pereira, J. L., Hanson, J., Suarez-Almazor, M. E., & Bruera, E. D. (2000). Occurrences, causes, and outcome of delirium in patients with advanced cancer. Archives of Internal Medicine, 160, 786-794.
  6. Breitbart, W., Marotta, R., Platt, M.M., Weisman, H., Derevenco, M., Grau, C., Corbera, K., Raymond, S. Lund, S., & Jacobsen, P. (1996) A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. American Journal of Psychiatry, 153(2), 231-237.
  7. Lerner, A.J., Hedera, P., Koss, E., Stuckey, J., & Friedland, R.P. (1997). Delirium in Alzheimer's disease. Alzheimer's Disease and Associated Disorders, 11, 16-20.
  8. Coy, E. & Ganzini, L. (2003). Delirium, anxiety, and depression. In R. S. Morrison & D. E. Meier (Eds.) (pp. 286-303). Geriatric palliative care. New York: Oxford University Press.
  9. Liptzin, B. & Levkoff, S.E. (1992). An empirical study of delirium subtypes. British Journal of Psychiatry, 161, 843-845.
  10. Sandberg, O., Gustafson, Y., Brannstrom, B., & Bucht, G. (1999). Clinical profile of delirium in older patients. Journal of the American Geriatrics Association, 47, 1300-1306.
  11. Raskind, M.A., Bonner, L.T., & Peskind, E.R. (2004). Cognitive disorders. In D.G. Blazer, D.C. Steffens, & E.W. Busse. Textbook of geriatric psychiatry. Washington, DC: American Psychiatric Publishing, Inc.