Delirium, Dementia, and Amnesia in Emergency Medicine Follow-up

  • Author: Paul S Gerstein, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Apr 22, 2011
 

Further Inpatient Care

All patients with unresolved delirium require admission and often require telemetry or ICU care.

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Further Outpatient Care

Workup for most cases of newly recognized dementia can be completed in an outpatient setting. In some cases, admission is needed until an appropriate living situation or a nursing home placement is arranged.

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Inpatient & Outpatient Medications

Outpatient medications for primary dementia are coordinated best by health care providers who have continuing contact with the patient. Medications may include the following:

  • Anticholinesterase inhibitors, such as donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon): These medications are useful early in the disease course, but they lose their effectiveness or may worsen mental status in advanced stages of the disease.
  • N -methyl D -aspartate (NMDA) receptor antagonists, including memantine (Namenda)
  • Antidepressants, especially the selective serotonin reuptake inhibitors or bupropion (Wellbutrin): Avoid tricyclic antidepressants because of their anticholinergic properties, which can worsen dementia.
  • Benzodiazepines for sedation or sleep: These drugs may worsen cognitive deficits and increase the risk of falls.
  • Antipsychotics for psychotic ideation or aggressive behavior: High-potency agents are preferred. Risperidone (Risperdal), a newer atypical antipsychotic, is well tolerated and useful for sundowning. However, the atypical antipsychotics as a group have been associated with a slightly higher death rate in patients with dementia (3.5% vs. 2.3% for placebo). Despite a US Food and Drug Administration (FDA) black box warning, experts warn against abandoning this class of medications in the treatment of dementia-related psychosis and aggression.
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Deterrence/Prevention

Various substances are thought to prevent or retard the onset of dementia, perhaps via preservation of CNS supporting cells, prevention of CNS inflammation, or free-radical inhibition.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs): The mechanism of action is thought to involve prevention of CNS inflammation.[8] More recent studies suggest that heavy NSAID intake is a risk factor for dementia; however, moderate intake may delay but not prevent dementia onset.[9]
  • Vitamin E: The suggested dose for prevention is 200-400 IU/d; much higher doses are sometimes given for treatment. The mechanism of action may be free-radical inhibition. Efficacy is controversial.
  • Vitamin B-6, vitamin B-12, and folate: These reduce levels of homocysteine, a potential brain neurotoxin.
  • Statin cholesterol-lowering medications: Reports suggest that these drugs substantially protect against dementia via an effect not related directly to blood levels of cholesterol. Mechanisms of action may be reduction of insulin levels in the brain and/or C-reactive protein (CRP) levels in the blood (indicative of inflammation). A study of more than 17,000 adults older than 60 years in Finland concluded that statins appeared to reduce risk by 58%.[10]
  • A high intake of dietary fats and calories is associated with an increased risk of Alzheimer disease.

Undertreated depression, hypertension, diabetes mellitus, hypercholesterolemia, and obesity have all been associated with higher risk of Alzheimer disease.

Excessive amounts of alcohol act as a neurotoxin and can increase Alzheimer diseaserisk. In moderate doses, alcohol inhibits cerebrovascular disease although it may still enhance brain atrophy. However, recent studies suggest that moderate drinking is protective against dementia as compared with abstinence. Antioxidants in wine (bioflavonoids) may be additionally beneficial (over spirits and beer). Red wines grown in more grape-stressful climates (eg, upstate New York) contain the highest concentrations of these nutrients.

Sedentary lifestyle is a risk factor for dementia, whereas regular exercise is protective.

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Complications

Delirium is a true medical emergency. Failure to recognize and aggressively treat the underlying cause can be catastrophic.

Delayed recognition of dementia can result in trauma secondary to cognitively impaired driving and the use of other hazardous equipment, including cooking stoves.

Patients with dementia are at increased risk of victimization by predatory business practices, Internet scams, and other fraudulent or criminal attacks.

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Prognosis

Delirium is fully reversible in most cases with proper recognition and treatment of the etiology.

Dementia is usually insidious and relentlessly progressive. However, about 20-30% of cases are due to reversible causes. On average, patients with Alzheimer disease die within 8 years of onset, with a range of 2-15 years. Younger patients usually have a more fulminant course. Pick disease has a similar course.

Subacute organic brain syndrome (OBS), or encephalopathy, may be reversible, persistent, or progressive.

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Patient Education

For excellent patient education resources, visit eMedicine's Dementia Center. Also, see eMedicine's patient education articles Dementia Overview, Dementia Medication Overview, and Possible Early Dementia.

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Contributor Information and Disclosures
Author

Paul S Gerstein, MD  Attending Physician, Emergency Department, Baystate Mary Lane Hospital

Paul S Gerstein, MD is a member of the following medical societies: American Academy of Emergency Medicine and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Coronal T1-weighted MRI scan in a patient with moderate Alzheimer disease. Brain image reveals hippocampal atrophy, especially on the right side.
 
 
 
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