Archive for the ‘mild cognitive impairment’ Category

Hospital-induced delirium: part one: the basics

Friday, July 13th, 2012

When they return from surgery, will some be delirious?

About two months ago I visited a friend in the hospital. He's a little over 80 years old, has several significant chronic medical problems and had recently undergone surgery. When I arrived in his room, he was in bed, didn't recognize me and then sat up and started rowing. Obviously he was delirious and hallucinating.

I've seen him at home since and he's back to baseline, but the topic of post-surgery delirium surfaced in the July 4, 2012 issue of JAMA, so I started reading on the subject

I found an article in a 2004 issue of the American Journal of Psychiatry (AJP) that was a good start, but was clearly aimed at medical folk, especially those who would be prescribing medication for the mostly severely affected patients with delirium. The AJP piece said the first step is determining the cause...if possible. It mentioned that the word itself comes from the Latin word delirare, loosely translated as "to be out of one's furrow." My online dictionary defines delirium as an acute (as opposed to chronic) disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.

The most recent mental health Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, a much-used but somewhat controversial tome (I'll write about the DSM in a later post), says delirium is a syndrome (a collection of symptoms and physical signs) of many different causes and that its major features are confusion and loss of short-term memory. It mentions one classic sign, not seen in all cases by any means, is carpologia, a term I'd never heard before, but a behavior I've seen many times; it means picking at the bed sheets in a purposeless, repetitive fashion. The patient may be agitated, have delusions and hallucinations, and may try to remove their IV lines or climb out of bed.

On the other hand, some people have a lethargic, hypoactive form of the syndrome; those may be even tougher to diagnose.

A Mayo Clinic website mentions one hallmark of delirium is a sudden or relatively sudden onset with symptoms that tend to wax and wane. Input from family members as to the patient's pre-illness/surgery mental status may be very helpful in sorting out those who had pre-existing dementia from those who didn't, as the two conditions not infrequently co-exist.

too much alcohol can lead to delirium

It's not just surgical patients, of course; when I was in practice the term internists used was "ICU-itis, and medical patients, especially the elderly who were in Intensive Care for a prolonged period, were the ones we had to deal with most commonly. So a better term might be hospital-induced delirium. But some delirious patients have ingested substances causing the condition (PCP would be one example and alcohol withdrawal another), have heavy metal poisoning, medication-caused delirium, infections involving the central nervous system or metabolic disorders.

It's common, but much more so in older patients and a 2010 meta-analysis of forty-two high-quality studies concluded that delirium in this group is associated with poor outcomes, regardless of age, gender, preceding dementia, and other illnesses.

I'll come back to this frequent and often ominous issue in my next post. As our population ages, we'll likely see more of this condition. Planning in advance for hospital stays may help prevent some episodes of delirium.



Thanks for the Memory: Part one

Thursday, June 14th, 2012

keep in touch with your older friends

My wife and I recently talked about the consequences of aging, physical and mental, and I decided to order a booklet from Harvard Medical School titled "Improving Memory: Understanding age-related memory loss." Then we set out on a Monday through Friday visit to old friends (literally, since most were more than 85 years old and at least five were over ninety). We flew from Denver to a city we once lived in and saw ten individuals/couples over the ensuing four days.

I remembered a family occasion fourteen years ago when my Dad and another elderly relative were talking about whether they'd rather be as they were, over ninety and suffering various aches and pains, but mentally sharp, or like another senior at the dinner was, a year or so older and healthy physically, but over the Alzheimer's cliff. They both voted for being creaky, but lucid.

The older friends we visited in three locales on the recent trip reminded me of Dad's discussion back in 1998. Most were a little frail and complained of a variety of back, leg and joint issues, but they were mentally right on target. On the other hand, I wondered if several had at least mild cognitive impairment.

Then we came home and I started reading the booklet. There are seven normal types of memory problems: a tendency to forget thing over time (transience), absentmindedness, blocking, misattribution, suggestibility, bias, and persistence. All of these can be worsened with age  without implying more severe brain issues: Alzheimer's, other dementias or even mild cognitive impairment.

The missing letters may not mean Alzheimers

I had the second of those seven problems yesterday, seeing a new member of my men's book group on the front steps of the house we were meeting in, introducing ourselves by first names and then sitting through a detailed discussion of a book, The Inventor's Dilemna, over the next two hours.

One of the seniors we visited on our trip had always been superb with names and even in her mid-80s is much better than most of us. I never had that talent and, of course, I have even less of it at age 71.

I had made no real attempt to store the other guy's name, didn't give him one of my usual memory-hook mental pictures, and totally forgot it by the time we left. One trick to overcome absentmindedness is using cues. I'm a "visual-verbal" person, and so I tend to superimpose an unusual tie or a mustache or something similar and then repeat  the cue to myself. When I do that, I remember names. In his case, I hadn't done so.

The book from Harvard has ten ways to promote memory health. One was very striking to me: "Get a good night's sleep." I sometimes read late into the night, 11:30 or 12 or even 12:30, and when I do I'm a tad groggy in the morning. That's not something I should do if I want to be at my best the next day.

So, having been in their company for a few minutes to several hours at most, I wouldn't even venture a guess as to whether the older friends we had eaten a meal with, or talked with for five or ten minutes, were mentally totally normal for their age and encountering one of the seven types of age-related memory problems we'll all have to cope with, or, possibly, had more severe issues.

But I will use the ideas in the book from Harvard Medical School.