Cognitive Disorders

1. Cognitive Disorders YASER ALHUTHAIL, MD ASSOCIATE PROFESSOR PSYCHOSOMATIC MEDICINE

2. Disruption in one or more of the cognitive domains, and are also frequently complicated by behavioral symptoms. Cognitive disorders exemplify the complex interface between neurology, medicine, and psychiatry Delirium, dementia, and the amnestic disorders

3. Delirium Acute onset of fluctuating cognitive impairment (global)and a disturbance of consciousness. Delirium is a syndrome, not a disease, and it has many causes, all of which result in a similar pattern of signs and symptoms A common disorder: 10 to 30 percent of medically ill inpatients 30 percent of patients in intensive care units and 40 to 50 percent of patients who are recovering from surgery for hip fractures Underrecognized and undertreated !!

4. Classically, delirium has a sudden onset (hours or days) A brief and fluctuating course Rapid improvement when the causative factor is identified and eliminated Abnormalities of mood, perception, and behavior are common psychiatric symptoms Tremor, asterixis, nystagmus, incoordination, and urinary incontinence are common

5. Risk Factors Extremes of age Number of medications taken Preexisting brain damage (e.g., dementia, cerebrovascular disease, tumor) History of delirium Alcohol dependence Diabetes Cancer Sensory impairment Malnutrition

8. Diagnostic Criteria for Delirium Due to General Medical Condition A-Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. B-A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. C-The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. D-There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

9. Diagnosis and Clinical Features The core features of delirium include: Altered consciousness Altered attention, which can include diminished ability to focus, sustain, or shift attention Impairment in other cognitive functions, which can manifest as disorientation and decreased memory Fluctuations in severity and other clinical manifestations during the course of the day, sometimes worse at night (sundowning) Disorganization of thought processes Perceptual disturbances Psychomotor hyperactivity and hypoactivity

10. The major neurotransmitter hypothesized to be involved in delirium is acetylcholine Anticholinergic activity Laboratory Workup of the Patient with Delirium Blood chemistries (including electrolytes, renal and hepatic indexes, and glucose)   Complete blood count with white cell differential   Thyroid function tests   Serologic tests for syphilis   Human immunodeficiency virus (HIV) antibody test   Urinalysis   Electrocardiogram   Electroencephalogram   Chest radiograph   Blood and urine drug screens

11. Differential Diagnosis Dementia Depression Schizophrenia Course and Prognosis The symptoms of delirium usually persist as long as the causally relevant factors are present Delirium is a poor prognostic sign

12. Treatment The primary goal is to treat the underlying cause The other important goal of treatment is to provide physical, sensory, and environmental support Pharmacotherapy haloperidol risperidone, clozapine, olanzapine, quetiapine

13. Dementia Global impairment of cognitive functions occurring in clear consciousness Difficulty with memory, attention, thinking, and comprehension. Other mental functions can often be affected, including mood, personality, judgment, and social behavior Can be progressive or static ! Permanent or reversible(e.g., vitamin B12, folate, hypothyroidism) 50 to 60 percent have the most common type of dementia, dementia of the Alzheimer's type Vascular dementias account for 15 to 30 percent of all dementia cases

14. Possible Etiologies of Dementia Degenerative dementias   Alzheimer's diseaseFrontotemporal dementias (e.g., Pick's disease)   Parkinson's diseaseLewy body dementiaMiscellaneous   Huntington's disease   Wilson's disease   PsychiatricPseudodementia of depression   Cognitive decline in late-life schizophreniaPhysiologic Normal pressure hydrocephalusMetabolic   Vitamin deficiencies (e.g., vitamin B12, folate)Endocrinopathies (e.g., hypothyroidism)   Chronic metabolic disturbances (e.g., uremia)Tumor   Primary or metastatic (e.g., meningioma or metastatic breast or lung cancer) Traumatic   Dementia pugilistica, posttraumatic dementia   Subdural hematomaInfectionPrion diseases (e.g., Creutzfeldt-Jakob disease, bovine spongiform encephalitis, Gerstmann-Strأ¤ussler syndrome)   Acquired immune deficiency syndrome (AIDS)   SyphilisCardiac, vascular, and anoxia   Infarction (single or multiple or strategic lacunar)   Binswanger's disease (subcortical arteriosclerotic encephalopathy)   Hemodynamic insufficiency (e.g., hypoperfusion or hypoxia)Demyelinating diseases   Multiple sclerosisDrugs and toxins   Alcohol, Heavy metals,  Carbon monoxide

15. Dementia of the Alzheimer's Type The most common type of dementia Progressive dementia The final diagnosis of Alzheimer's disease requires a neuropathological examination of the brain Genetic factors Acetylcholine and norepinephrine, both of which are hypothesized to be hypoactive in Alzheimer's disease

16. Vascular Dementia The primary cause of vascular dementia, formerly referred to as multi-infarct dementia, is presumed to be multiple areas of cerebral vascular disease Vascular dementia is more likely to show a decremental, stepwise deterioration than is Alzheimer's disease.

17. Diagnosis and Clinical Features The diagnosis of dementia is based on the clinical examination Memory impairment is typically an early and prominent feature Early in the course of dementia, memory impairment is mild and usually most marked for recent events; As the course of dementia progresses, memory impairment becomes severe, and only the earliest learned information are intact Orientation can be progressively affected

18. Personality change, intellectual impairment, forgetfulness, social withdrawal, anger and lability of emotions are common Hallucinations………….20 to 30 percent Delusions………………30 to 40 percent Physical aggression and other forms of violence are common in demented patients who also have psychotic symptoms. Depression and anxiety symptoms Pathological laughter or crying

19. Diagnostic Criteria for Dementia of the Alzheimer's Type A-The development of multiple cognitive deficits manifested by both 1-memory impairment (impaired ability to learn new information or to recall previously learned information) 2-one (or more) of the following cognitive disturbances: aphasia (language disturbance) apraxia(impaired ability to carry out motor activities despite intact motor function) agnosia(failure to recognize or identify objects despite intact sensory function) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) B-The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. C-The course is characterized by gradual onset and continuing cognitive decline. D-The cognitive deficits in Criteria A1 and A2 are not due to any of the following: 1-other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor) 2-systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection) 3-substance-induced conditions E-The deficits do not occur exclusively during the course of a delirium. F-The disturbance is not better accounted for by another Axis I disorder (e.g., major depressive disorder, schizophrenia

21. Dementia Due to Other General Medical Conditions HIV disease, head trauma, Parkinson's disease, Huntington's disease, Pick's disease, and Creutzfeldt-Jakob disease. Substance-Induced Persisting Dementia Alcohol-Induced Persisting Dementia

22. Physical Findings, and Laboratory Examination A comprehensive laboratory workup must be performed when evaluating a patient with dementia The purposes of the workup are to detect reversible causes of dementia The evaluation should follow informed clinical suspicion Differential Diagnosis Delirium Depression (pseudodementia ) Schizophrenia Normal Aging

24. Treatment The first step in the treatment of dementia is verification of the diagnosis. Preventive measures are important Supportive and educational psychotherapy Any areas of intact functioning should be maximized by helping patients identify activities in which successful functioning is possible Caregivers

25. Pharmacotherapy Benzodiazepines for insomnia and anxiety Aantidepressants for depression Antipsychotic drugs for delusions and hallucinations Drugs with high anticholinergic activity should be avoided. Cholinesterase inhibitors : Donepezil (Aricept), rivastigmine (Exelon), galantamine (Remiryl), and tacrine