eMedicine Specialties > Emergency Medicine > Neurology

Delirium, Dementia, and Amnesia: Follow-up

Author: Paul S Gerstein, MD, Attending Physician, Baystate Mary Lane Hospital Emergency Department
Contributor Information and Disclosures

Updated: Jan 17, 2008

Follow-up

Further Inpatient Care

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

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.

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.
    • NMDA receptor antagonists - 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). In spite of a FDA black box warning, experts warn against abandoning this class of medications in the treatment of dementia-related psychosis and aggression.

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.
    • Estrogen: In women, use of estrogen at any time in life may decrease the risk of AD by greater than 50%. This may be because of the preservation of CNS supporting cells. This is controversial.
    • Nonsteroidal anti-inflammatory drugs (NSAIDs): The mechanism of action is thought to involve prevention of CNS inflammation. The newer COX-2 inhibitors, such as celecoxib (Celebrex), are being investigated for their effectiveness for prevention of dementia. This is controversial.
    • Vitamin E: The dose for prevention is 200-400 IU/d; higher doses are sometimes given for treatment. The mechanism of action may be free-radical inhibition.
    • Vitamin B-6, vitamin B-12, and folate: These reduce levels of homocysteine, a potential brain neurotoxin.
    • Statin cholesterol-lowering medications: Recent reports suggest that these drugs substantially protect against dementia via an effect not related directly to blood levels of cholesterol. This finding has not yet been verified by clinical trials but appears promising (see References).
    • A high intake of dietary fats and calories is associated with an increased risk of AD.
  • Undertreated depression, hypertension, diabetes mellitus, hypercholesterolemia, and obesity have all been associated with higher risk of AD.
  • Excessive amounts of alcohol act as a neurotoxin and can increase AD risk. In moderate doses, alcohol inhibits cerebrovascular disease while it may still enhance brain atrophy. 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.

Complications

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

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 AD 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 OBS (encephalopathy) may be reversible, persistent, or progressive.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The major pitfall is failing to exclude organic causes for mental status change when evaluating a patient presumed to have an acute psychiatric illness. In addition, significant organic illness may coexist with, but be masked by, psychobehavioral disturbances.
    • Difficulty obtaining a reliable history and poor patient cooperation with physical examination may complicate the workup. Therefore, a high index of suspicion and a diligent examination are required to avoid missing a critical diagnosis.
    • "Medical clearance" examinations are risky. Typically brief, these evaluations are rarely sufficient to rule out organic etiologies. Do not document: "Patient is medically cleared." If necessary, state: "No clear-cut organic etiology is evident at this time. Further evaluation may be needed depending on the clinical setting."
  • Vital signs often are overlooked in the setting of acute behavioral disturbance.
    • Be sure to obtain a temperature at some point in the evaluation.
    • Be certain that abnormal vital signs are rechecked before transfer out of the ED.
  • Know ED and hospital regulations and regional statutes regarding the use of physical restraints and involuntary psychiatric commitment.
    • Document reasons for restraining a patient, mentioning patient and staff safety and protection. Document reasons for involuntary commitment and be sure to follow all COBRA regulations when transferring.
    • Do not order: "Restrain prn." Give specific reasons for applying and removing restraints. Have restrained patient continuously observed. Personally ensure that restraints are applied in a safe manner.
    • In most cases, chemical restraint is preferable to physical restraint when prolonged behavioral control is necessary or when the patient is severely combative. Serious injury or death can result from intense or prolonged struggling against restraints.

Special Concerns

  • Do not assume that dementia in an elderly person is irreversible, particularly when of recent onset. Search diligently for a reversible or modifiable cause.
    • Workup may be initiated in the ED and continued in an outpatient setting.
    • Admission may be required for the safety of the patient, even when inpatient workup or treatment is unnecessary.
  • Be wary of occult causes for changes in mental status.
    • Hypoxia (eg, pulmonary embolism), hypercarbia, carbon monoxide poisoning, hypoglycemia, hypothyroidism, hyperthyroidism, hypercalcemia, hyponatremia, temporal lobe seizure, and postictal states may cause changes in mental status.
    • Myocardial infarction in elderly persons can cause delirium.
    • Infection may cause changes in mental status, and fever can be absent. Check the skin carefully for cellulitis, rash, and petechiae. Have a low threshold for lumbar puncture.
    • Signs may be subtle in CNS trauma. For example, only a CT scan can diagnose shaken baby syndrome. Be sure to look carefully for other signs of abuse. Consider occult subdural hematoma in elderly persons.
 


More on Delirium, Dementia, and Amnesia

Overview: Delirium, Dementia, and Amnesia
Differential Diagnoses & Workup: Delirium, Dementia, and Amnesia
Treatment & Medication: Delirium, Dementia, and Amnesia
Follow-up: Delirium, Dementia, and Amnesia
References
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References

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  2. American College of Emergency Physicians. Clinical policy for the initial approach to patients presenting with altered mental status. Ann Emerg Med. Feb 1999;33(2):251-81. [Medline].

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  4. American Psychiatric Association. Mental disorders due to a general medical condition. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Fourth Edition. Washington, DC: American Psychiatric Association; 1994:165-74.

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Further Reading

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Keywords

acute confusional state, ACS, mental status change, MSC, organic brain syndrome, OBS, altered mental status, confusion, amnesia, long-term memory disturbance, Alzheimer dementia, Alzheimer's dementia, Alzheimer's disease, Alzheimer disease, AD, senility, transient global amnesia, TGA, encephalopathy, subacute OBS, head trauma, mass lesions, hydrocephalus, multi-infarct dementia, atrophy, dementing processes, delirium tremens, severe hypoglycemia, CNS infection, heat stroke, thyroid storm, Wernicke syndrome, Wernicke's syndrome, drug intoxication, alcohol intoxication, drug withdrawal, alcohol withdrawal, AIDS-related dementia, Creutzfeldt-Jakob disease, pseudodementia, repeated lacunarstrokes, aspirin toxicity, heat illness, hyperthermia, diabetic ketoacidosis, sepsis, narcotic overdose, dehydration, asphyxia, complete heart block, seizure disorder, acute mania, endocrine crisis, renal failure, liver failure, neoplasia, cerebral vascular accident, CVA, respiratory dysfunction, shock, sundowning, Korsakoff syndrome, Korsakoff's syndrome, Korsakoff psychosis, postconcussive syndrome, frontotemporal dementia, FTD, Pick disease, Pick's disease, thalamic stroke, neurosyphilis, meningitis, encephalitis, anoxia, dementia pugilistica, punch drunk, avitaminosis, systemic lupus erythematosus, SLE, giant cell arteritis, sarcoidosis, schizophrenia, Wilson disease, copper storagedisease, lipid storage diseases

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Contributor Information and Disclosures

Author

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

Medical Editor

Eric Kardon, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Athens Regional Medical Center
Eric Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

J Stephen Huff, MD, Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
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.

CME Editor

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, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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