DELIRIUM, DEMENTIA, AMNESTIC AND OTHER COGNITIVE DISORDERS

1. DELIRIUM, DEMENTIA, AMNESTIC AND OTHER COGNITIVE DISORDERS Cherryl Velasco Francia, M.D., D.P.B.P. Psychiatry and Behavioral Medicine

2. quiz • Give 1 subcategory for 1. Delirium 2. Dementia 3. Amnestic Disorder 4.-6 What functions of the brain are impaired in cognitive disorders • Give one therapeutic agent for 7. Delirium 8. Dementia 9. What is the most common type of dementia? 10. Give one medical condition which could cause delirium

3. OBJECTIVES 1. To define the following terms: • Delirium Amnesia • Dementia Transient Global Amnesia • Pseudodementia  2. To enumerate the different subcategories of the cognitive d/o 3. To know the clinical manifestations of different cognitive d/o 4. To explain the etiologic factors of the Cognitive Disorders

4. OBJECTIVES 5. To list the diagnostic aids for cognitive disorders 6. To perform the Minimental State Examination 7. To differentiate delirium from dementia 8. To differentiate dementia from pseudodementia 9. To know the course and prognosis of the cognitive disorders

5. IMPAIRED COGNITION • IMPAIRED MEMORY • IMPAIRED LANGUAGE • IMPAIRED ATTENTION

6. DELIRIUM Subcategories • Due to General Medical Condition • Substance-Induced • Multiple causes • Delirium NOS

7. DEMENTIA Subcategories • Dementia of the Alzheimer’s Type (DAT) • Vascular Dementia • Dementia Due to Other Medical Conditions • Substance Induced • Dementia of Multiple Etiologies • Dementia NOS

8. AMNESTIC DISORDER Subcategories • Due to a Medical Condition • Due to Toxins or medications • Amnesia NOS

9. DELIRIUM .

10. DELIRIUM • syndrome • underrecognized and undxd • Acute confusional state • Acute brain syndrome • Metabolic encephalopathy • Toxic psychosis • Acute brain failure

11. DELIRIUM • Short-term confusion and changes in cognition • Impaired consciousness • Neuropsychiatric abnormalities • Rapid improvement when causative factor is identified and eliminated

12. DELIRIUM • Point Prevalence : 0.4 (18 – 54 y.o.) 1.1 (55 y.o. and above) • 10-30% of medically ill hosp’d patients - 30% in surgical and cardiac icu - 40-50% in pts recovering from hip fracture surgery • more than 90% in postcardiotomy pts • 80% of terminally ill patients

13. CAUSES OF POSTOPERATIVE DELIRIUM • Stress of surgery • Postoperative pain • Insomnia • Pain medication • Electrolyte imbalance • Infection • Fever • Blood loss

14. RISK FACTORS FOR DELIRIUM 1. Advanced age 2. Preexisting brain damage 3. History of delirium 4. Alcohol dependence, DM, Cancer, Malnutrition, Sensory Impairment 5. Male gender

15. DELIRIUM • Poor prognostic sign • institutionalization inc’d 3-fold for aged 65 and above • 23-33% = 3-month mortality • 50% = 1 year mortality • 20-75% mortality rates for elderly hosp’d patients

16. MAJOR CAUSES OF DELIRIUM • Central Nervous System Diseases • Systemic Diseases • Intoxication or Withdrawal from Pharmacologic or Toxic Agents

17. BIOLOGICAL HYPOTHESES OF DELIRIUM • Decreased Acetylcholine activity in the brain • Dysfunction of the reticular formation • Hyperactive Locus ceruleus • Noradrenergic dysfunction

18. CORE FEATURES OF DELIRIUM • Altered consciousness • Decreased level of consciousness • Altered attention • Disorientation • Decreased memory • Rapid onset, brief duration • Fluctuation in severity throughout the day

19. ASSOCIATED CLINICAL FEATURES OF DELIIRIUM • Disorganized thought processes • Perceptual Disturbances • Psychomotor hyperactivity or hypoactivitry • Disrupted sleep-wake cycle • Mood alterations • Altered neurological function • EEG : diffuse slowing of background activity

20. DELIRIUM LABORATORY WORK-UP • Blood chemistries – CBC, electrolytes, renal and liver indices, glucose levels, thyroid function tests • Serologic tests for syphilis • HIV antibody test • Urinalysis • ECG EEG Chest x-ray • Blood and urine Drug screens

21. DIFFERENTIAL DIAGNOSESIN DELIRIUM • Dementia • Schizophrenia • Schizophreniform Disorder • Dissociative disorder • Depression

22. COURSE AND PROGNOSIS OF DELIRIUM • Prodrome – restlessness, fearfulness • Symptoms persist as long as cause is still present • Generally lasts less than a week • Upon removal of causative factor, symptoms recede within a 3-7 day period (up to 2 weeks) • Older patient, longer period of delirium, longer resolution of the symptoms

23. PHARMACOTHERAPYIN DELIRIUM • Manage psychosis and insomnia • Haloperidol for psychosis : 2-10mg IM, • Start twice daily oral dose with 2/3 of the dose given at night (5-50mgdaily) • Avoid Phenothiazines • Benzodiazepines for Insomnia – short or intermediate acting (Lorazepam)

24. DEMENTIA .

25. DEMENTIA • Diminution in cognition • Severe impairment in memory, judgment, orientation and cognition • Stable level of consciousness • Persistent and stable nature of impairment • Multiple cognitive defects • Progressive or static; permanent or reversible • Significant impairment in functioning

26. DEMENTIA Prevalence Rate (USA) 1.5 (> 65 y.o.) 16-25% (>85 y.o.) 5% of persons >65 y.o. = severe dementia 15% of persons > 65 y.o. = mild dementia 20% of persons > 80 y.o. = severe dementia Of all types, DAT is the most common (50-60%)

27. RISK FACTORS FOR ALZHEIMER’S DISEASE • Female • First degree relative • History of head injury • Down syndrome

28. DEMENTIA of ALZHEIMER'S TYPE 75% of all cases 1907 Alois Alzheimer Amyloid deposits in the brain – hallmark neuropathology Genetic Factors – Chr 1, 14,21 Amyloid Precursor Protein – long arm ch 21 Multiple E4 Genes

29. DEMENTIA of ALZHEIMER’S TYPE Neuropathology: diffuse atrophy with flattened cortical sulci and enlarged cerebral ventricle

30. DEMENTIA of ALZHEIMER’S TYPE Pathognomonic microscopic findings: senile plaques neurofibrillary tangles neuronal loss synaptic loss granulovascular degeneration of neurons

31. DEMENTIA of ALZHEIMER’S TYPE Senile plaques – Amyloid plaques composed of particular protein, B/A4 , astrocytes, dystrophic neuronal processes and microglia

32. DEMENTIA of ALZHEIMER’S TYPE Neurofibrillary tangles – cortex, hippocampus, substantia nigra, locus ceruleus - cytoskeletal elements (phosphorylated tau proteins)

33. DEMENTIA of ALZHEIMER’S TYPE • Neurotransmitters : hypoactive acetylcholine and norepinephrine • Specific degeneration of cholinergic neurons in nucleus basalis of Meynert • Decreased Ach & Ache in the braindecreased # of cholinergic neurons

34. DEMENTIA of ALZHEIMER’S TYPE • Decreased NE, somatostatin and corticotrophin activity • Excessive stimulation of glutamate • Abnormal regulation of membrane phospholipid metabolism

35. VASCULAR DEMENTIA Multiple cerebral vascular disease Most common in men Small and medium sized cerebral vessels affected Infarction of the vessels- multiple parenchyma lesions

36. OTHER CASUES OF DEMENTIA • Pick’s Disease • Lewy Body Disease • Huntington’s Disease • Parkinson’s Disease • HIV Related Dementia • Head Trauma

37. CLINICAL EATURES OF DEMENTIA Intellectual impairment and forgetfulness Evasion, denial, rationalization and concealing of cognitive deficits Excessive orderliness Social withdrawal Sudden outbursts of anger Lability of emotions Sloppy grooming

38. PSYCHIATRIC AND NEUROLOGICAL CHANGES IN DEMENTIA Personality Changes Hallucinations and Delusion Mood Cognitive Change Catastrophic Reaction Sundowner Syndrome

39. DEMENTIA vs PSEUDODEMENTIA ?

40. CLINICAL EVALUATIONIN DEMENTIA • Psychiatric, medical, neurologic history and examination • Comprehensive laboratory work-up • MRI • SPECT

41. DEMENTIA:CLINICAL EVALUATION • Psychiatric History • Mental Status Examination • Tests for Cognitive Function – MMSE • Memory • Visuospatial and Constructional abilities • Reading, Writing and Mathematical abilities • Abstraction

42. MINI-MENTAL STATE EXAMINATION .

43. DELIRIUMvs.DEMENTIA

44. DELIRIUM vs DEMENTIA

45. DEMENTIA:ANCILLARY TESTS • EEG • Computed Tomography • Magnetic resonance Imaging • Positron Emission Tomography • SPECT

46. COURSE AND PROGNOSIS OF DEMENTIA • Onset : 50-60s, gradual deterioration over 5-10 years death • Subtle signs during the onset • Average survival : 8 years for DAT • Regression of symptoms is a possibility of reversibility once treatment is initiated • Steady progression, incremental worsening or stable course

47. MANAGEMENTOF DEMENTIA • Control of medical illness • Psychosocial therapies for the patient and patient caregiver • Pharmacotherapy • Donepezil • Galantamine • Rivastigmine • Tacrine

48. AMNESTIC DISORDER • Acquired and impaired ability to learn and recall new information • Inability to recall previously learned knowledge or past events • Alcohol use • Head injury • Affected areas : diencephalic structures

49. TRANSIENT GLOBAL AMNESIA ?

50. MAJOR CAUSES OF AMNESTIC DISORDER • Systemic medical conditions – B1 def’y • Hypoglycemia • Primary Brain Conditions – seizures, head trauma, tumors, cvd, surgery of the brain, encephalitis due to herpes simplex, hypoxia, TGA, ECT, MS • Substance-Related Causes – alcohol, neurotoxins, bzd, OTC preparations