Recognizing Cognitive Dysfunction

Christopher Sanders, MD
Augusta Health Palliative and Transitional Care

Cognitive dysfunction, including its more advanced form, dementia, is a highly common condition affecting approximately 8% of the population, or about 30 million people in the United States. The prevalence increases with age and is associated with other disabling conditions, decreased mobility, increased burden of other diseases, multiple medications, procedures, and hospitalizations.

Dementia, in its many forms, including Alzheimer’s, vascular dementia, frontotemporal dementia, alcohol use-related dementia, and Lewy Body Dementia, is linked to the specific anatomic disordering of the brain. Dementia is a neurologic condition studied by neurologists who manage cases with the patient’s primary clinician. It had historically been regarded as a psychiatric diagnosis, and it may be hard to separate from other psychiatric diagnoses such as depression.

Cognitive dysfunction and dementia develop over the long haul, whereas rapid or sudden onset suggests other diseases, and the assessment of cognitive dysfunction must always include a detailed evaluation for other medical problems such as thyroid disorders, medication side effects, metabolic disorders, including liver and kidney diseases, as all of these can have an impact on someone’s mental clarity.

Patients with dementia may have associated behavioral problems and superimposed psychiatric diagnoses as well. A recent study identified that of nursing home patients with dementia, one in three are on two or more psychiatric medications, and one in eight is on three or more such medications. There was an unfortunate period in our history where antipsychotics and sedatives were used excessively without appropriate diagnoses or monitoring for side effects in nursing home residents. That has changed since the Omnibus Budget Reconciliation Act (OBRA) of 1987, which limited the use of psychotropic medications in residents of long-term care facilities and mandated documentation of necessary periodic trials of medication withdrawal via specific Resident Assessment Instruments. The OBRA reforms dramatically shifted to comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. In the aggressive move to comply with these standards, there has been a shift to focus on identifying non-psychiatric causes of increasing confusion.

Delirium is a mental state characterized by three findings:
1) a fluctuating, altered level of awareness, ranging from agitation to stupor
2) delusional thinking, meaning a disturbed perception of reality
3) the presence of a medical condition that would precipitate such an acute neurologic deterioration.

Delirium can be precipitated by any overwhelming, acute medical condition. All people, including children and young adults, can become delirious if sick enough, but the elderly and specifically those with underlying dementia are much more susceptible. Delirium is a health emergency with serious adverse, long-term consequences. There are currently no medications that have been successfully found to avert or treat delirium, but rather, some medications, such as sedatives, may dispose people toward it and are thus avoided. The incidence of delirium in demented patients who are sick enough to wind up in the ICU approaches 100%.

Patients with cognitive dysfunction and dementia who are brought to the emergency department for worsening of their mental status should be evaluated for delirium, but this is challenging in that setting as the diagnosis may require several hours of observation, sometimes warranting hospitalization to reach diagnosis. Recent medication changes should always be considered, as should any new medical findings such as metabolic disorder or infection, but getting a good history of symptoms to guide the investigation can be challenging for a patient whose primary problem is acute worsening of chronic cognitive dysfunction.

While bacterial or viral infection is an important potential source of delirium and should be treated without delay, in-depth assessment for a source of infection should be limited to patients who display signs of general infection, such as fever or elevated white count, or other specific signs of infections. Pursuing an infectious workup in the absence of these is regarded by experts as unproductive. A case in point is urine sampling without fever, white count, or urinary symptoms to suggest infection, as chronic bladder colonization with bacteria is common in older impaired patients (up to 50% of long-term care residents, per the Infectious Disease Society of America), and the urinalyses and cultures of those patients will always suggest bacteria even when there is no true infection. This is particularly true for patients with chronic urinary catheters, where the incidence of colonization is 100%. Administering antibiotics in that setting only serves to increase the risk of drug-resistant bacteria and possible dangerous bowel infections without any benefit to the patient. It is specifically advised by the US Agency for Healthcare Research and Quality, for example, that urine not be sent on elderly patients who are confused but have none of the above-mentioned signs of infection. This is becoming the standard of care.

Alterations in mental status are stressful not only for the patient but for their loved ones as well. When major illness and hospitalizations occur in the cognitively impaired, it is helpful to have clear-cut expectations discussed in advance, a designated Health Care Power of Attorney, and good lines of communication with your family and health care provider. 

Augusta Health welcomes Christopher Sanders, MD, to the Palliative Care Team. For more information on Palliative Care, please visit augustahealth.com/service/palliative-care.