Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Anita Nitchingham,1,2 Gideon A Caplan1,2 1The Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia; 2Department of Aged Care, Prince of Wales Hospital, Sydney, NSW, AustraliaCorrespondence: Anita NitchinghamDepartment of Aged Care, Ground Floor, Edmund Blackett Buil...

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Autores principales:	Nitchingham A, Caplan GA
Formato:	article
Lenguaje:	EN
Publicado:	Dove Medical Press 2021
Materias:	delirium dementia delirium superimposed on dementia ageing Neurosciences. Biological psychiatry. Neuropsychiatry RC321-571 Neurology. Diseases of the nervous system RC346-429
Acceso en línea:	https://doaj.org/article/3be08f9838714f96a18c1a9987565aee
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spelling	oai:doaj.org-article:3be08f9838714f96a18c1a9987565aee2021-12-02T14:47:30ZCurrent Challenges in the Recognition and Management of Delirium Superimposed on Dementia1178-2021https://doaj.org/article/3be08f9838714f96a18c1a9987565aee2021-05-01T00:00:00Zhttps://www.dovepress.com/current-challenges-in-the-recognition-and-management-of-delirium-super-peer-reviewed-fulltext-article-NDThttps://doaj.org/toc/1178-2021Anita Nitchingham,1,2 Gideon A Caplan1,2 1The Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia; 2Department of Aged Care, Prince of Wales Hospital, Sydney, NSW, AustraliaCorrespondence: Anita NitchinghamDepartment of Aged Care, Ground Floor, Edmund Blackett Building, Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, AustraliaTel +61293824252Fax +61293824241Email a.nitchingham@unsw.edu.auAbstract: Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an “acute exacerbation” of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.Keywords: delirium, dementia, delirium superimposed on dementia, ageingNitchingham ACaplan GADove Medical Pressarticledeliriumdementiadelirium superimposed on dementiaageingNeurosciences. Biological psychiatry. NeuropsychiatryRC321-571Neurology. Diseases of the nervous systemRC346-429ENNeuropsychiatric Disease and Treatment, Vol Volume 17, Pp 1341-1352 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	delirium dementia delirium superimposed on dementia ageing Neurosciences. Biological psychiatry. Neuropsychiatry RC321-571 Neurology. Diseases of the nervous system RC346-429
spellingShingle	delirium dementia delirium superimposed on dementia ageing Neurosciences. Biological psychiatry. Neuropsychiatry RC321-571 Neurology. Diseases of the nervous system RC346-429 Nitchingham A Caplan GA Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia
description	Anita Nitchingham,1,2 Gideon A Caplan1,2 1The Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia; 2Department of Aged Care, Prince of Wales Hospital, Sydney, NSW, AustraliaCorrespondence: Anita NitchinghamDepartment of Aged Care, Ground Floor, Edmund Blackett Building, Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, AustraliaTel +61293824252Fax +61293824241Email a.nitchingham@unsw.edu.auAbstract: Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an “acute exacerbation” of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.Keywords: delirium, dementia, delirium superimposed on dementia, ageing
format	article
author	Nitchingham A Caplan GA
author_facet	Nitchingham A Caplan GA
author_sort	Nitchingham A
title	Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia
title_short	Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia
title_full	Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia
title_fullStr	Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia
title_full_unstemmed	Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia
title_sort	current challenges in the recognition and management of delirium superimposed on dementia
publisher	Dove Medical Press
publishDate	2021
url	https://doaj.org/article/3be08f9838714f96a18c1a9987565aee
work_keys_str_mv	AT nitchinghama currentchallengesintherecognitionandmanagementofdeliriumsuperimposedondementia AT caplanga currentchallengesintherecognitionandmanagementofdeliriumsuperimposedondementia
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Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

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