Friday, September 24, 2010

Differences Between Delirium, Depression Dementia, Delusions, Alzheimer's

Lots of D's to differentiate.
Alzheimer's disease is one form or type of dementia. The most common form or type of dementia. Dementia is the loss of cognitive ability. A global generic term. There are many other causes of dementia besides the most common Alzheimer's disease. Lewy body dementia, Vascular dementia, traumatic brain injury induced, to name a couple.
The different forms of dementia may look slightly different in their clinical symptoms and presentation and progression.
Dementia is a chronic problem it is typically slow and often progressive.
Delirium is way different. A delirium is an acute confusional state, or an encephalopathy. It generally comes in pretty quickly, hence the term "acute". There is always a cause for delirium. It may be a metabolic problem, eg. not enough oxygen to the brain or too much carbon dioxide, such as someone with really bad lung or heart disease, or a metabolic problem, someones sodium for example is too high or low, or a toxicity, such as illicit drugs or drug withdrawal, alcohol withdrawal is a common cause. A severe infection with for example a high fever is another cause.
Delirium is always a medical emergency. It can have a high death rate up to 25% or more, especially if not treated.  Usually it is very treatable, the issue is diagnosing it and finding the cause. 
Often it is mistaken for a psychiatric problem. A common symptom is visual hallucinations, seeing things, example bugs crawling on the wall. Sometimes there are tactile hallucinations, feeling things that are not there, such as bugs crawling on one's skin. These kind of hallucinations usually again indicate an "organic" or medical reason and problem.
A person can get extremely agitated in delirium, bizarre, violent aggressive behavior, it often gets worse at night and fluctuates over the course of the day. Sundowning is a term that has been associated with delirium.
A person with dementia can get agitated and worse at night. We also associate the term sundowning with Alzheimer's also, or more agitation at night. Wandering about etc.
A person with dementia can also develop a delirium on top of that. A common cause for example is a person that has Alzheimer's dementia and develops a urinary tract infection, or a metabolic imbalance.
That is where it gets more difficult to diagnose. Usually there is more of an acute change in the persons behavior, a significant worsening or change over hours or a few days.
One of the key things in telling the difference between delirium and dementia is that a person's level of consciousness fluctuates in delirium. They are in and out of consciousness, from awake and alert to sleepy somnolent, to hyperalert and agitated. Sometimes they are difficult to wake up, and may go from sound asleep and difficult to rouse to extremely agitated in a matter of seconds.
A person with dementia typically will not go in and out of consciousness so abruptly. They will be awake and alert, maybe completely impaired with memory, concentration, orientation, but they will be alert.
Another key thing is since delirium is a medical or organic problem, a person with have "autonomic fluctuations"  This means there vital signs will fluctuate a lot over the course of the day. Remember it is a medical problem. So their blood pressure may go up and down they may have fevers that come and go, pulse rate may fluctuate. In someone with dementia only, you would not see much fluctuation in vital signs on a daily basis. But if they are not checked you would not know.
It is something a doctor (or medical provider) really needs to diagnose and find the cause of and treat.
As I have stated ion previous blog posts auditory hallucinations are typically associated with a psychiatric disorder, that is "hearing voices" of people that are not there. Unfortunately visual versus auditory hallucinations are not always distinguished by medical people outside of the psychiatric realm of specialists. Hence you can see another reason why it gets confusing.
Delusions are a symptom of psychosis. They are false ideas or beliefs. They can be of different types. Paranoid- eg "aliens planted a computer in my brain" or Ssomatic (physical) there are snakes in my belly eating my insides" Delusions are typically asassociated with a psychiatric disorder, such as schizophrenia, they are fixed and ongoing, however they can also develop in someone with dementia. And in fact are not uncommon as Alzheimer's disease progresses.
Delusions can also be seen in a delirium, but there are so many other things going on when a person has a delirium a fixed delusional belief is usually not a paramount symptom, since the whole medical problem is quickly developing and acute.
The paranoia associtated with for example Alzheimer's is a little bit different say than someone with schizophrenia. The false beliefs in dementia, may be more variable, and less fixed and tend to come and go, more than in a functional psychiatric disease.
but the issue of delusional beliefs is one of those quandaries that makes everyone ask is Alzheimer's a medical or a psychiatric problem (see previous posts).
The delusional material is often treated with anti-psychotics, it may not completely go away, but the person tends to be much less obsessed concerned with or likely to act on their delusional beliefs if they are treated. We then run into all the problems and well publicized issues with antipsychoitcs and the warnings in the elderly etc. (see previous posts).
Hallucinations are also treated with antipsychotics, they are not quite so common in dementia but certainly can and do occur, maybe not as often as delusional beliefs though.
you would not want to start treating visual hallucinations without simultaneously find the cause of any delirium. Auditory again are more common in psychiatric disorders, and it is less likely to find a delirium or medical cause, so the hallucinations are treated there also, and often respond quite well to antipsychoitc meds.
Depression is a psychiatric disorder, that is now more openly talked about over the last 15 years or so, so it has made its way into the mainstream of primary care and is regularly more screened for in general medicine, It is much more socially acceptable to talk about depression. Depression can have a high morbidity- loss of job, divorce, substance abuse) and be fatal for example by suicide if it is not treated. 
Persons with dementia can also develop depression, but often unlike someone without dementia they can't necessarily tell us about it or how bad they fell because they are already cognitively impaired.
Here is where it gets even more tricky. Back in the day not so long ago, there used to be a common term called "pseudo-dementia". It was associated with depression. In fact it still is, but the term is no vogue anymore. Probably too confusing for everyone. Here's what it means- a person with depression has lots of symptoms- sad, hopeless, helpless, suicidal, insomnia, low energy, weight loss, for example to name a few, but a person suffering from major depression can also be cognitively slowed. They can be sluggish in memory and thinking. It can be mistaken for dementia,
As a person ages they are at increased risk for developing Alzheimer's, but if they are depressed and have absolutely no dementia, they may still have cognitive slowing from the depression and be misdiagnosed with dementia. IT HAPPENS A LOT. With the health care debacle it will happen even more as we will tend to want to diagnose ourselves or have our friends do it. This is why a medical work-up and psychiatric work up and evaluation is so important.
With health care rationing already here, I am very fearful that there will be many people misdiagnosed or simply not treated. People with Alzheimer's being misdiagnosed with depression and vice versa
Now one final problem, a person can have Alzheimer's disease brewing and depression at the same time. In fact depression can be the first sign of Alzheimer's. The diagnosis of one or both has to be made and differentiated by a medical professional. untreated depression can make the Alzheimer's worse.

Monday, September 20, 2010

The Double Whammy

Most of my posts in the past have been about my dad and his battle with dementia but today going to talk about my mom. We have known that my mother has been having some memory problems herself, dating back for the last 1.5 to 2 years, roughly. So, in August, we took my mom in for a neuropsychological evaluation. The results came back with a dementia diagnosis, significant cognitive impairment, likely Alzheimers type dementia. So, mom and dad, ages 70 and 72, both have dementia. The double whammy. We have now started mom on the same memory medications that my dad has been on, so hopefully that will slows things down. But the whole situation remains very difficult for me to wrap my mind around.

Another thing that has occurred to me recently is the number of head injuries my dad may have had during his lifetime. He played a lot of football during an era of thin leather helmets, and his occupation left him open to physical injuries. I can remember his head being cut or bloodied many times. He also rode motorcycles and for a while semi-pro, he once had a wreck in which his jaw was broken and his teeth had to be wired shut for several weeks. Leaves me wondering how much of this accumulated history may be impacting his current condition.

The other news is that we have moved my folks to a new assisted living/dementia care home. The place is significantly nicer and we hope that they will be much more comfortable there.

Thanks be to God....JP

Tuesday, September 14, 2010

As The Present Fades

I am still amazed at this point that I can still converse with you and tell you how things are going in my journey or battle if you will. In the beginning and still now i am prepared for the mental walkings and goings but I was never prepaired for the physical problems.  Walking with a swagger, actually kind of a stumble and hunched, feeling icky most of the time, getting exttermely upset around people and sweaty like a pig, shaking like i do, not able to hold things all the time, just not ready for this crap.

I find my world in fading in and out now. I recognize family and people and suddenly they start to become someone else. Same person standing there but my brain seems to switch off and step back and say who the fuck is that. I am finding this to be happening more and more, I feel like i am fading away from Joe and going somewhere and I cannot stop it anylonger. I really wish I would hear from others in this world of mine and what they are going through and how they feel. It is really a lonely place, yes I have people around me that care and help, not the same, they are not here with me, in my reality such as it is.

I must go now my mind is confused and i am getting very angry.

God Bless You & This Country of Ours!

PS.  Hi Doc, this is from my blog today, love you my friend.

Friday, September 10, 2010


Well it is back to school time. N Minnesota saw a really hot summer. On the Western Terminus of Lake Superior it gets hot a few times every summer, up around 90 degrees. But it only lasts a few days here and there. This summer it was hot in the 80's for days on end, sometimes for weeks at a time. By American standards that is not really much, considering how warm it gets in other parts of the country. Right after labor day, it was like instant fall. Now it gets cold for the next 10 months. The temperature correlates with peoples attitudes. I mean the cold grates on you, I don't know how Canadians do it. Yes you can always wear three coats, bu t it still wears you out spiritually. Most people that live in the cold, pretend it does not bother them, or they are not even aware how it affects them. We like to think about the daylight, and seasonal affective disorder, and the pineal gland and melatonin and all that fun stuff, that has modest scientific review. Yes it does exist, but nobody really considers the cold.
Well we will try avoiding using the furnace for as long as possible. Hopefully can get another month in.
Lots of unhappy anniversary dates in September. It is exactly 10 years ago September 10, since I ruptured my Achilles tendon, simply paying tennis. That seemed to take forever to get better. Then on September 12th it will be exactly one year ago since I broke my face in three places falling off a scooter. See old blogs, hard to believe this blog has been up for over a year already. My face still hurts. I still don't know how I went back to work in a week back then , if only out of necessity.
Then a few months ago in going through my mother's old scrap book, I found out it was September 10th 1933, when she was in a tragic car accident. She was 16 and sustained a fractured skull. Interestingly she was back to school in a couple week after being in a coma. See old blogs about head injuries and development of Alzheimer's.
Then of course we have 9/11 for all Americans, 9 years and we all remember what we were doing when we heard, I know I do.
On the good side of September we have the start of football season. Nice night for the Saints and the city of New Orleans last night and not too good for local fans around here as the Vikes take a hit.
Well as the seasons continue to fly by, take care of yourselves, as a caregiver you still get to be human. Remember the day is only 24 hours, unlike the legendary Alzheimer's book says, you will all make it. The days grow shorter now, except for our friends in Australia and N Zed. If you live in a place where the leaves change, get out and take a serious walk over the next month and enjoy it. If you can take your loved one with you safely, then go for it, or just go for a drive. Everyone likes to go for a ride. The kids, the dog, people with AD. Where I live interestingly it goes from green to white. In other words sometimes it snows before the maple trees even turn yellow and orange or think about loosing their leaves. But time keeps marching on.

Friday, September 3, 2010

Alzheimer's and old memories, memory loss, long term memory preservation

One of the important aspects about Alzheimer's disease and memory loss is the fact that the last part of the memory to decline is the long term memory. In other words your loved one will not remember very recent things,, from the here and now, what they ate for dinner four hours ago for example, but they will remember stuff from forty or fifty years ago quite clearly. Sometimes they can remember events from the 1950's or 60's like it was yesterday. There is trouble storing new and recent memories, but the old ones last a really long time in the disease process. It is just the nature of how the disease process works.
They might not know who the current president is, but they might remember some interesting things about JFK or the moon landing or even Pearl Harbor if they are old enough.
You might use this to connect with your loved one. Music is a wonderful area where long term memory is preserved, and it generally calms the mind and soul to hear music "from our time".
Old photographs also can sometimes stimulate mood, memory and the spirit.
It is a strange thing for people to see and observe sometimes, how can you not remember what day it is or what month, but you can tell me the name of your third grade teacher?
Ultimately the long term memories will also decline as the disease progresses, but use them while you have them. It is freeing and a wonderful way to connect. Don't worry if the old memories are not exactly accurate, just connect to your loved one through them.
You might even learn something historical and interesting that you never would have known had you not tried.

Talking about the book with the Lake Superior wind....... a calm day