Cognitive Disorders Theme

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

2. Abdullah is a 72-year-old male. He was brought to the A/E by his son for vomiting, new onset urinary incontinence, confusion, and incoherent speech for the past 2 days. The patient was disoriented and could see people climbing trees outside the window. He had difficulty sustaining attention, and his level of consciousness waxed and waned. He had been talking about his deceased wife. Patient was also trying to pull out his intravenous access line. Past history included diabetes mellitus, hyperlipidemia, osteoarthritis, and stroke. The patient's family physician had recently prescribed Tylenol with codeine for the patient's severe knee pain 5 days earlier.

3. On examination : drowsy, not cooperative with the physical examination. Abdomen :flat and soft with normal bowel sounds. The patient moves all 4 limbs and plantar is bilateral flexor. Laboratory tests : elevated BUN and creatinine levels, and the urine analysis was positive for UTI. CT scan of the head showed cortical atrophy plus an old infarct.

4. Psychopathology Consciousness Orientation Attention Concentration Memory

5. 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

6. 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 !!

7. 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

8. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. Past history inquiry indicated that he has two years of deteriorating memory.He forgets mostly recent things and has difficulty to name some familiar people. 6 months ago, he lost his ability to drive and to pray appropriately. However, his attention was well except of few days’ prior current admission. There is positive family history of sever memory problem in his eldest brother.

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

25. 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

26. 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

28. 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

29. 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

30. Abdullah’s son reluctantly reported that his father has current history of occasional alcohol drinking . He admits that he was a heavy alcohol drinker 10 years ago. He had bouts of memory impairments and family problem secondary to his heavy drinking. He used to have tremors and craving for drinking at early morning. After searching patient’s old medical notes, you found that the patient has been admitted to ICU 10 year ago with fever, sweating, tremor, dilated eyes, disorientation, confusion and seeing small animals.  Moreover, the patient’s medical notes indicates that he came to ER 25 years ago complaining of runny nose, stomach cramps, dilated pupils, muscle spasms, chills despite the warm weather, elevated heart rate and blood pressure, and low grade fever. At that time, he has asked ER physician some “meds” to tide him over until he can see his regular doctor.

31. Abuse: Self-administration of any substance in a culturally disapproved manner that causes adverse consequences. Dependence: The physiological state of neuroadaptation produced by repeated administration of a drug, necessitating continued administration to prevent the appearance of the withdrawal state. Addiction: A nonscientific term that implies dependence.

32. Intoxication:The transient effects (physical and psychological) due to recent substance ingestion, which disappear when the substance is eliminated. Withdrawal:A group of symptoms and signs occurring when a drug is withdrawn or reduced in amount. Tolerance:The state in which the same amount of a drug produces a decreased effect, so that increasingly larger doses must be administered to obtain the effects observed with the original use.

33. Risk factors of Alcohol abuse Vulnerable personality:impulsive, less conforming, isolated or avoidant persons. Vulnerable occupation:senior businessmen, journalists, doctors. Psychosocial stresses:social isolation, financial, occupational or academic difficulties, and marital conflicts. Psychiatric problems:anxiety, chronic insomnia depression.

34. Alcohol Withdrawal Stages Symptoms Peak severity at 36 hours Most cases self-limited  Stage I symptoms “Delirium Tremens” Protracted withdrawal • I (24 – 48 hours): • II (48 – 72 hours): • III (72 – 105 hours): • IV (> 7 days):

35. Alcohol withdrawal 85% mild-to-moderate 15% severe and complicated: Seizures Delirium Tremens Features : Tremulousness (hands, legs and trunk). Nausea, retching and vomiting. Sweating, tachycardia and fever. Anxiety, insomnia and irritability. Cognitive dysfunctions. Thinking and perceptual disturbances.

36. Delirium Tremens (DTs) Features: Delirium. Gross tremor . Autonomic disturbances . Dehydration and electrolyte disturbances.. Marked insomnia. Course : Peaks on third or fourth day, lasts for 3 – 5 days Complications : Seizures. Chest infection, aspiration. Violent behaviour. Coma. Death; mortality rate: 20%. >>>>>>>> Medical emergency

37. Treatment The best treatment is prevention Supportive Thiamine Long acting BDZ (chlordiazepoxide 25-50 mg every 2-4hrs )………(50-100 mg every 4 hrs) Avoid antipsychotics.

38. Complications of chronic ETOH abuse

39. OPIOIDS Heroin, morphine, codeine, pethidine, methadone . They are abused for their powerful euphoriant effects . Tolerance develops rapidly & diminishes rapidly!! Withdrawal symptoms: 6 hours after the last dose, reach a peak after 36 - 48 hours, and then wane. Severe craving, very distressful but have no serious medical consequences Lacrimation, muscle and joint pain, cold and hot flushes, nausea, vomiting and diarrhoea, and piloerection

40. Opioids ( clinical effects) • Treatment: • *Opioid overdose : supportive +naloxone • *Opioid Withdrawal: symptomatic treatment, Counseling, • individual or group therapy • * Harm reduction strategies: methadone

41. Valid Informed Consent Permission given by a competent person without any elements of force, deceit, coercion after explanation and disclosure of: Purpose and details of procedure or treatment Risks, Benefits and available alternative treatment/s The right to withdrawal consent verbally or in written forms at anytime Exceptions!!!

42. Being mentally ill doesn’t in itself imply a loss of capacity or competency. Having Capacity or being Competent until proven otherwise.

43. To have capacity to consent to “treatment”, 4 criteria must be satisfied in a patient: To understand relevant information about the PROPOSED treatment/ treatment OPTIONS/ NO treatment Able to communicate a choice consistently To appreciate own clinical situation (insight) with regard to the proposed treatment (if a patient is in denial of illness, s/he will not be considered competent) To rationally manipulate (reasonable; sensible; sound judgment) provided information/s