Dementia and Prehospital Implications (ALS)

Assessment Of This Case

In 1900, there were 3.1 million Americans 65 years or older. In 2000, that number
was 35 million and it is expected to rise by 74% before the year 2020. As our
society ages, the number of cases of elderly patients seen by EMS is sure to
increase. As dementia is primarily a disease of the elderly, it is important to be
familiar with the nuances of caring for and treating the demented patient. 1  

Dementia is a general loss of mental capacity and intellectual capacity,

with symptoms of cognitive deterioration, typically occurring slowly, and in most
cases, irreversible. Most cases of dementia in the United States are secondary to
Alzheimer’s, a neu- rodegenerative disorder of unknown etiology. Vascular
dementia is the second most common cause. Dementia affects about 1% of the
population between the ages of 60–64, and a shocking 30–50% of folks older than
85 years old. It is the most common reason elderly are placed in nursing homes.
Alzheimer’s dementia typically involves a slow deterioration in memory, and the
ability to think, learn, communicate and handle daily activities. As many as 5.3
million people in the United States have Alzheimer’s dementia, and it is currently
the seventh leading cause of death. From 2000–2006, deaths from Alzheimer’s
disease increased 46%.

The 10 Warning Signs Of Alzheimer's

According to the Alzheimer’s Association, the 10 warning signs of Alzheimer’s include: 4

1. Memory loss that disrupts daily life

2. Challenges in planning or solving problems

3. Difficulty completing familiar tasks at home, at work, or at leisure

4. Confusion with time or place

5. Trouble understanding visual images and spatial relationships

6. New problems with words in speaking or writing

7. Misplacing things and losing the ability to retrace steps

8. Decreased or poor judgment

9. Withdrawal from work or social activities

10. Changes in mood or personality

Dr. Katz Reflects

Seeing many elderly patients in the Emergency Department that suffer from various
degrees of dementia, I am always curious to meet dementia patients that can tell
you specific details about their childhood from 70 years earlier, but cannot
remember what they ate an hour ago. Dementia certainly has a predilection for
short-term memory loss, compared to long-term memory, at least in the initial
stages of dementia. As dementia progresses, long-term memory is also affected
and patients may no longer be able to carry out basic life functions like feeding
oneself or getting dressed.

Geriactric Emergencies

Geriatric Emergencies represent a significant percentage of EMS calls. With our

population aging, it is important to be proficient in dealing with the confused elderly
patient. There are many possible reasons to explain why an elderly patient may
present with altered mental status. Being familiar with the many common, and not
so common, reasons for an elderly person to have confusion are of paramount
importance to today's EMS professional. Avoid making assumptions; do not assume
that the older confused patient simply has worsening dementia. Family members of
demented patients that spend a lot of time with an individual are often very astute
at noticing new behavioral changes compared to a patient's baseline. As demented
patients are difficult to evaluate, because of limitations obtaining an accurate
history, any concern about a change in baseline mental status should prompt
serious concern and investigation.  Keep in mind the possibility of
overdose, metabolic abnormalities, infection, alcohol, attempted suicide and a host
of other possibilities.  Many of these may not be on the top of your list of possible
explanations for the confused behavior, but must be considered in order to be
thorough and to avoid an error in judgment.

Unreliable Historians

When you are dealing with a patient who is an unreliable historian, it is critical that
you attempt to gather your history from any available family member or bystander.
Also keep in mind your thoroughness in conducting a scene survey as this could
prove extremely useful if important clues are found. Be on the lookout for medicine
bottles and check the refrigerator to see if it contains an adequate food supply
and/or medications. Check the dates that medication bottles were filled and
determine if there are too many pills or too many pills missing. It is not uncommon
for elderly patients with short term memory problems or depression to take too
much or too little of their medicine; both can lead to problems. Malnutrition
and dehydration are also possibilities particularly in the homebound elderly patient
with inadequate social support mechanisms in place. You must be a detective.
Piecing together all of the available clues at your disposal can provide very useful
information.

When The Crew Arrives On Scene

They are presented with an 80-year-old man who is obviously confused. It is

immediately clear, upon initial contact with our patient, that the patient is an
extremely poor historian. Appropriately, the crew on scene maximizes their history-
taking skills by acquiring as much information as possible from the patient’s
daughter and with a thorough scene survey. When interviewed, the patient’s
daughter tells the crew that her father has been acting more confused than usual
for the past 1–2 days. She informs the crew that her father recently “bumped” his
head and had an occasional cough. There has been no depression or suicidal
ideation, and no known ingestions. It’s always a good idea to ask how the patient’s
present mental status compares with his or her baseline. Our patient lives with his
daughter. As far as his daughter knows, he has been taking all of his medications
and has not had any recent changes in medication dosages.

ABC's

Airway:  Airway is clear without signs of obstruction.   

Breathing:  Breathing is unlabored, with a rate of 16, and a resting O 2  saturation of
93% (an important clue).  Oxygen is immediately applied.
Circulation:   Pulses are present and irregular. Heart rate is 102.

Immediate Treatment

 Personal protective equipment

 Scene safety/Prevention of injury

 ABCs/Oxygen

 History

 Vital signs

 Physical examination

 Paramedic care: IV, blood sugar evaluation

It is critically important in a scenario when you are treating a dementia patient that
you are calm, non-threatening, and treat your patient with sensitivity.  Perform a
scene survey, assess the ABCs, provide oxygen as needed, perform a thorough
history, complete vital signs, and thorough physical exam. A blood sugar should
also be checked.  With these patients your detective skills will really come into
play.   It is going to be the clues that you discover during the scene survey, vital
signs, and physical exam that are going to help paint the picture with these types
of challenging calls. 

Scene Survey

Our scene survey in this scenario reveals nothing out of the ordinary. When called
to respond to a scene in a home, the scene survey in an elderly demented patient
should always include looking for any safety hazards, or poor living conditions that
may need to be relayed to either law enforcement or hospital personnel.
Malnutrition and dehydration are also possibilities particularly in the homebound
elderly patient with inadequate social support mechanisms in place.

“DEMENTIA” Mnemonic

“ DEMENTIA ” Mnemonic for Altered Mental Status 3

Drug s   (side-effects of   medication , overdose, withdrawal)

Electrolyt e
abnormality   ( hyponatremia ,   hypernatremia , hypoglycemia ,   hyperglycemia )
Metaboli c disturbance   ( thyroid   disease, liver failure, kidney failure)
Emotiona l   ( depression ,   psychosis )
Nutritiona l   (Wernicke’s encephalopathy, Korsakoff’s psychosis)/Neuro (stroke, sei-
zure, intracerebral bleeding)
T rauma , Tumor, Toxin  
Infectio n   (urinary tract   infection ,   pneumonia ,   meningitis , etc.)
Alcoho l   (ethanol, ethylene glycol, methanol)

Hypoglycemia

One of the most common reasons for altered mental status in the field
is hypoglycemia. This typically occurs in the insulin-dependent diabetic who has
either not eaten enough or may have an underlying infection. Hypoglycemia is
easily diagnosed with a blood glucose check.

Stroke

Stroke is another large category that can explain altered mental status, particularly
in the elderly. When evaluating the possible stroke patient, make sure to test the
patient's ability to follow commands. A patient may have a stroke affecting their
speech center, but may not have any difficulty understanding and following
commands. Standardized stroke scales should be utilized if stroke is suspected.
Infection/Sepsis

Another common reason for altered mental status. Temperature is a very important
vital sign to obtain, particularly in the older patient with altered mental status. The
patient with altered mental status and a fever is much more likely to have
an infection as the reason for their altered mental status. Common infections in the
elderly are pneumonia and urinary tract infections. These patients should be asked
history questions that assess for possible infections.

Metabolic Abnormalities

Such as hyperglycemia, hypoglycemia, hypernatremia (high sodium levels),

or hyponatremia (low sodium levels) can cause altered mental status. Both
hypernatremia and hyponatremia are common in the dehydrated elderly patient.
The elderly are at higher risk for electrolyte abnormalities, particularly if
medications are taken incorrectly or underlying illness is
present. Metabolic disturbances, like thyroid disease, liver failure, or kidney failure,
are also possibilities but will be difficult to detect in the field.

Psychiatric Reasons

Altered mental status, such as depression and psychosis, are also possible causes

of altered mental status. However, these should be diagnoses of exclusion and
should not be diagnosed in the field.

Nutritional Considerations

There are also nutritional considerations ,  such as Wernicke's encephalopathy, that

can cause altered mental status. Wernicke's encephalopathy is typically a reversible
condition usually resulting from alcohol abuse and thiamine deficiency. It is often
associated with confusion, ataxia, nystagamus (i.e.rapid eye movements), and
vision difficulties.

Trauma

Ask about trauma. Sometimes older patients with underlying memory disorders

may not remember falling. Ask bystanders or nursing home staff if there may have
been any recent trauma or falls. Look for signs of head trauma. Is there any
bruising present? Is there bruising around the eyes or behind the ears that may
indicate a basilar skull fracture? Does the patient complain of a headache?
The elderly are the most rapidly growing segment of the population, making up
12% of the population. However, they are responsible for 36% of all EMS
transports, 25% of hospitalizations, and 25% of all trauma costs. Approximately
15,000 people older than 65 die each year from falls. Treating the elderly patient
who has fallen can be tricky because there can be a multitude or reasons why your
elderly patient has fallen. When injured, the elderly are much more likely to die
from their injuries than the younger trauma patient, making them a much higher-
risk patient population. Being familiar with the many different physiologic and
unique differences in the elderly trauma will make you much more adept at treating
the elderly EMS patient.

Ingestions

How about ingestions? Is there any reason to suspect the patient may have
intentionally or unintentionally overdosed on medications or drugs? Elderly people
are not immune from depression and suicide attempts. Sometimes asking the
difficult and awkward questions can elicit a tremendous amount of valuable
information. Alcohol dependence has been found to be present in up to 4% of
community-dwelling elderly persons.
Consider neurological causes of altered mental status. These could include stroke, seizure, or intracerebral
bleeding.

Alcohol

Alcohol in any form (ethanol, ethylene glycol or methanol) could be a possibility for
a patient's altered mental status.

Coma   – a state of unconsciousness from which the patient cannot be aroused.

Wernicke's encephalopathy  – a reversible confusion resulting from thiamine deficiency
and usually associated with alcohol abuse. Often associated with
confusion, ataxia, nystagmus, and ophthalmoplegia (i.e. paralysis of the eye
muscles).
Korsakoff's syndrome  – an irreversible psychosis associated with chronic thiamine
deficiency. Seen almost exclusively with alcoholism, it is often associated
with amnesia.
Delirium  – a reversible alteration in mental functioning, i.e. infection,
poisoning, drug intoxication, drug withdrawal, metabolic disturbances, hepatic
failure, renal failure, seizures, head trauma.
Dementia  – a general loss of intellectual abilities that is typically not reversible, slow
onset, and usually associated with structural neurologic disease, i.e. Alzheimer's,
cerebrovascular disease, brain trauma, brain tumors, multiple sclerosis, Parkinson's
disease.

Preliminary Diagnosis
It is difficult to make assumptions about the confused elderly patient. The
demented patient with increased confusion compared to baseline can have multiple
reasons to explain their condition including: Trauma, Infection, Electrolyte
abnormality, Seizure, medication overdose (accidental or intentional), intoxication,
and cardiopulmonary issues like CHF, MI, pulmonary embolism, and hypoxia. Based
on our clues of the patient having increased confusion compared to baseline, a
head contusion, fever, and mild hypoxia, our concerns include possible head
injury and infection (i.e. pneumonia).

Pearls Of Wisdom

Do not make assumptions about the confused elderly patient. The patient you think
may be having a stroke may be hypoglycemic, postictal from a recent seizure, or
even intoxicated.
Do not assume that alcohol and/or drug abuse is not possible because the patient is
elderly. Be thorough, perform a thorough history and physical exam, be methodical,
and avoid making assumptions.
The brain is extremely sensitive and vulnerable to swelling and compression of
underlying brain tissue. The hard skull that encases the brain does not allow for
protection of healthy brain tissue when significant bleeding and swelling occur.
When intracerebral bleeding and swelling occurs, intracranial pressure rises which
can be fatal.

When treating the head-injured patient it is important to be prepared for possible

vomiting. The patient on a backboard may need to be placed on their left side to
avoid aspiration. Having suction readily available is always a good idea with the
potential head-injured patient.

Patients taking coumadin, especially the elderly with any evidence of trauma, no
matter how seemingly minor, should be considered high risk for an intracerebral
injury. I have seen many cases of patients with intracerebral bleeding as a result of
relatively minor head trauma when coumadin was being taken.

Glasgow Coma Scale

Glasgow Coma Scale :  standardized method using a scale from 3-15 to assess a

patient's level of consciousness by evaluating best eye opening, verbal, and motor
responses. This scale should be done on all patients with altered mental status and
repeat evaluations are useful. Repeat evaluations should be recorded with the times
that these were performed. This is helpful to the personnel at the hospital, and is
also extremely helpful if the case is ever later reviewed in a court of law.

What Is Aricept?

Many Alzheimer's patients take the drug Aricept with the intent of reducing the
progression of their Alzheimer's disease. Aricept is the trade name for the drug
donepezil. Donepezil is in a class of medications called cholinesterase inhibitors. The
drug is thought to improve mental function (such as memory, attention, social
interaction, reasoning and language abilities, and ability to perform activities of
daily living) by increasing the amount of a certain naturally occurring
neurohormones in the brain. Donepezil may improve the ability to think and
remember or slow the loss of these abilities in people who have AD. However,
donepezil does not cure AD or prevent the gradual loss of mental abilities in the
future.

Symptoms Of Aricept Overdose May Include

 nausea

 vomiting

 drooling

 sweating

 slow heartbeat

 difficulty breathing

 muscle weakness

 fainting

 seizures
Being aware of different commonly prescribed medications for dementia can be
helpful, especially if you have access to patient's medications and a good history is
unavailable.

Prescription Medications Used In The Treatment Of Dementia

 Aricept (donepezil)

 Exelon (rivastigmine)

 Namenda (memantine)

 Cognex (tacrine)

 Rezadyne (galantamine)

Documentation

Documenting your patient's mental status as specifically as possible is extremely

important. If  you respond to this type of scenario in someone's home document all
medicine bottles you discover. Check the dates that medication bottles were filled
and see if there are too many pills or not enough pills missing. It is not uncommon
for elderly patients with short-term memory problems or depression to take too
much or too little of their medicine, which can each lead to problems.  Document if
the living conditions are sanitary.  Check the refrigerator and document if it
contains an adequate food supply. Document if there are alcohol bottles that
appear to be recently emptied.  Don't assume just because your patient is elderly,
that they can't have a drug or alcohol problem.  Your specific documentation can
provide helpful clues.

What Happened To Our Patient?

At the Emergency Department, our patient was found to have a small subdural

hematoma that occurred 2 days earlier when he accidentally hit his head on a
cabinet, and a right-sided pneumonia. He was successfully treated and went home
to live with his daughter 6 days later, with a new emphasis placed on fall
precautions. 
As the population of elderly is increasing, and due to the
high prevalence of dementia, being familiar with the natural progression of
dementia and the unique challenges of caring for the demented patient is important
to today’s EMS Professional. Be thorough, avoid making assumptions, and try
to extract as many possible clues available from the scene survey, history, and
physical exam. Also, being aware of a demented patient’s baseline mental status
compared to their current presentation can help tune you into a new issue that may
now be present.
Glossary

Abuse  : Any form of maltreatment that results in harm or loss. Maltreatment may

be physical, sexual, psychological, or financial/material.
Body  : In the context of the uterus, the portion below the fundus that begins to
taper and narrow.
Brain  : Part of the central nervous system located within the cranium; contains
billions of neurons that serve a variety of vital functions.
Coma  : A state in which one does not respond to verbal or painful stimuli.
Command  : In incident command, the position that oversees the incident,
establishes the objectives and priorities, and from there develops a response plan.
Confusion  : An impaired understanding of one's surroundings.
Dehydration  : Depletion of the body's systemic fluid volume.
Dementia  : The slow onset of progressive disorientation, shortened attention span,
and loss of cognitive function.
Depression  : A persistent mood of sadness, despair, and discouragement; may be a
symptom of many different mental and physical disorders, or it may be a disorder
on its own.
Disposal  : A type of decontamination in which as much clothing and equipment as
possible is disposed of to reduce the magnitude of the problem.
Drift  : A finding that when the operator lets go of the steering wheel, a vehicle
consistently wanders left or right.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
fighting bacteria, or producing euphoria) when given in the appropriate
circumstances and in the appropriate dose.
Drug Abuse  : Any use of drugs that causes physical, psychological, economic, legal,
or social harm to the user or others affected by the user's behavior.
Extract  : A concentrated preparation of a drug made by putting the drug into
solution (in alcohol or water) and evaporating off the excess solvent to a prescribed
standard.
Head Injury  : A traumatic insult to the head that may result in injury to soft tissue,
bony structures, or the brain.
Hematoma  : An accumulation of blood in the tissues beneath the skin; a potential
complication of IV therapy.
Hypernatremia  : A blood serum sodium level greater than 148 mEq/L and a serum
osmolarity greater than 295 mOsm/kg.
Hypoglycemia  : Abnormally low blood glucose level.
Hyponatremia  : A blood serum sodium level that is below 135 mEq/L and a serum
osmolarity that is less than 280 mOsm/kg.
Infection  : The abnormal invasion of a host or host tissue by organisms such as
bacteria, viruses, or parasites, with or without signs or symptoms of disease.
Injuries  : Any unintentional or intentional damage to the body resulting from acute
exposure to thermal, mechanical, electrical, or chemical energy or from the absence
of such essentials as heat or oxygen.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG
that shows the electrical conduction in the heart.
Medication  : A licensed drug taken to cure or reduce symptoms of an illness or
medical condition or as an aid in the diagnosis, treatment, or prevention of a
disease or other abnormal condition.
Metabolic  : Pertaining to the breakdown of ingested foodstuffs into smaller and
smaller molecules and atoms that are used as energy sources for cellular function.
Mood  : A person's sustained and pervasive emotional state.
Planning  : In incident command, the position that ultimately produces a plan to
resolve any incident.
Pneumonia  : An inflammation of the lungs caused by bacteria, viruses, fungi, or
other organisms.
Postictal  : The period of time after a seizure during which the brain is reorganizing
activity.
Prevalence  : The number of cases of a disease in a specific population over time.
Psychosis  : Breaking with common reality and existing mainly within an internal
world.
Seizure  : A paroxysmal alteration in neurologic function, ie, behavioral and/or
autonomic function.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell,
and so on.
Skull  : The structure at the top of the axial skeleton that houses the brain and
consists of 28 bones that comprise the auditory ossicles, the cranium, and the face.
Subdural Hematoma  : An accumulation of blood beneath the dura but outside the
brain.
Suicide  : Any willful act designed to bring an end to one's own life.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Term  : Used to describe an infant delivered at 38 to 42 weeks of gestation.
Thyroid  : Large gland located at the base of the neck that produces and excretes
hormones that influence growth, development, and metabolism.
Trade Name  : The brand name registered to a specific manufacturer or owner; also
called proprietary name.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result
of the rapid dissipation of energy delivered by an external force.

References

1. Tintinalli, J. E. (2011). Emergency Medicine (7th ed.). New York: McGraw-

Hill.

2. Caroline, N.L. (2013). Nancy Caroline’s Emergency Care in the Streets (7th

ed.). Massachusetts: Jones and Bartlett Publishers.

3. Tueth, M. J. “Dementia: Diagnosis and Emergency Behavioral Complications”

Journal of Emergency Medicine 13:519, 1995.

4. Alzheimer’s Association (2013, July 10) www.alz.org “What is Alzheimers?”

as retrieved from www.alz.org/alzheimers_disease_what_is_alzheimers.asp.