Delirium, Dementia, Amnestic

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Delirium, Dementia, Amnestic Other Cognitive
Mental Dis

• By
• Narong Maneeton

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Organic VS Functional

• Organic Identifies Pathology
• Functional Schizophrenia
• Present All of Psychiatric Illness are
  Partially Organic Involved

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Cognitive

• The mental process of comprehensive , judgment ,
  memory , reasoning in contrast to emotional and
  volitional process

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Cognitive Dis

• Impair. of Cognition memory, Attention
• ???????? Delirium, Dementia, Amnestic
• Causes -General Medical Condition
• -Substance Induced
• -NOS

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Evaluation Of Cognitive Impairment

• MMSE
• Score lt 25/30 Suspected Cognitive Impairment
• Score lt 20/30 Absolutely Cognitive Impairment

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Delirium

• Clinical Symp.
• Impairment of Conciousness
• Impair. of Cognitive Func.
• Neurological sign
• Acute onset Fluctuation Course

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Epidemiology

• Incidence and Prevalence
• 10-15 gen. Surg 15-20 med. Ward
• 30 surg.ICU 40-50 Hip surg.
• 20 Severe Burn 30 HIV Pt.

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Predisposing factor

• Old Age or Very young Age
• Post-Operation Stress, Pain, Insomnia, Pain
  Medication
• Burn, Brain Damage , Alc. Withdrawal
• Past Hx. of Delirium , DM , CA

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• Sensory Impairment
• Malnutrition
• Pt. with AIDS
• 23-33 Death in 3 Mo.
• 50 Death in 1 Yrs.

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Cause of Delirium

• Medication
• Neurological cause
• Infection
• Metabolic Disorders
• Vitamin Deficiency

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• Endocrinopathy
• Withdrawal syndrome
• Drug abuse
• Toxin and Industrial Exposure

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Pathophysiology

• Ethanol, Barbiturate Benzodiapine Inhibition of
  GABA
• Inhibition of Cholinergic Transmission
• Early EEG Investigation

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Diagnosis

• 1. Delirium due to a general medical cond.
• 2.Substance intoxication delirium
• 3.Substance withdrawal delirium
• 4.Delirium due to multi. etiology
• 5.Delirium NOS

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Clinical Feature

• 1.Prodome Restless , Anxious , Irritable ,
  Hypervigilant , Drowsiness , Transient Hallu.
• 2.Fluctuating Course Change of emotion
  cognition , Diurnal variation Sundowners
  Syndrome
• 3.Attention Deficit

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4.Arousal disturbancePsychomotor
Ab. -Hyperactive Agitation, Restless,
Alertness, Hypervigilant Sedative-Hypnotic or
Alcohol Withdrawal -Hypoactive Lethargic,
Somnolence, Apathy, Demented , Depressed,
Catatonic, Quietly confused -Mixed
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5.Sleep-wake cycle disturbance -Reversed
sleep-wake cycle -Fragmented , Shorten
period6.Impaired language, memory, other
cog. -Rambling , Irrelevant , Incoherent -Impair
short-term memory caused by - loss
concentration , perceptual disturbance ,
malfunction of hippocampus
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7.Disorientation impair time and
place8.Altered Perception can not discriminate
stimuli and integrate - Hallucination9.Neurologi
cal Ab. -High cortical function
impairment -Tremor, Asterixis ,
Incoordination Urinary Incontinence
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Differential Diagnosis

• Dementia
• Depression
• Psychosis
• Dissociative disorder
• Catatonic

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Diagnostic Procedures

• Initial evaluation of life threatening
• Hx., PE. NS.,MSE
• Laboratory investigation
• -CBC
• -Blood Chemistry

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-TFT - Serologic test Syphilis, HIV -Drug
level -Arterial blood gas -U/A -EKG -Chest
X-ray
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Neurological investigation -EEG -CT, MRI,
SPECT, Other radiologic test -LP
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Management and Treatment

• General considerations
• -Specific Tx.
• -Tx. Of the etiology is unknown
• -Pharmacotherapy
• Antipsychotics Haloperidol

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Benzodiazepine Lorazepam Combined
Benz.Antipsychotics -Environment Restraint
Sedating until calm or sleep Vital sign q
30 min Re-evaluate q 12-30 min
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Orientation Clock, Calendar etc. No
sensory deprivation -Psychosocial
Intervention Reassurance simple,
briefly Prevent over stimuli Education for
Fm. Members Explain the bizzare Beh for Pt
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Course and Prognosis

• Recover after remove causes in 3-7 days
• Full recovery (most), Progress to stupor/coma ,
  Chronic brain syndrome, Seizure, morbidity, death

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Mortality

• 25 death in 3-4 Months
• Death increase in Pt with Underlying disease or
  Hyperautonomic activity
• Morbidity
• Rehabilitation

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Dementia

• Impairment of Cognitives, Normal Conciousness
• Impairment of general intelligent, learning,
  memory, language, problem solving, orientation,
  perception, attention, concentration, judgment,
  social ability
• Impairment of Function

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Epidemiology

• 15 Treatable
• 50 DAT
• 60 Yrs 5
• 80 Yrs 15-25
• 15-30 Vascular dementia

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Classification (Neuroanatomy)

• Cortical dementia DAT,Picks disease
• Subcortical dementia EPS, Hydrocephalus, White
  matter disease, Subcortical vascular dis.
• MixedVascular dementia, toxic metabolic
  condition, slow virus inv. Cortical Subcortical

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Dementia of Alzheimers Type(DAT)

• Definition
• Progressive degeneration of Cortex
• Impairment of Function
• Fragment of Neurofilament Microtubule

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Epidemiology

• 50
• Risk Female, 1stdegree Relative, Hx. Head
  injury, Downs syndrome
• 60 Yrs 5
• 80 Yrs 15-20

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Etiology

• Genetics Polygenic or Autosomal dominant
• Family 40 of DAT asso 1stdegree Relative
• gt 3-4 ???? ??? gen. Population
• Downs syndrome 20-40 Yrs.
• Brain growth factor

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-Head injury Dementia pugilistic or punch drunk
syndrome-Viral infection Creutzfeldt-Jacob
disease-Aluminum -Neurotransmitters
???? -Choline acetyltransferase -Serotonin -GAB
A -NE
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-Neuropathology -gen. Cerebral
Atrophy -Flattening cortical sulci -Senile
Plaque, Neurofibrilly tangle, neuronal loss
-Grandulovascular degeneration of neuron
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Vascular Dementia

• Male gt Female
• HT or Cardiovascular dis.
• Small medium Cerebral Vessel
• Lession gen. in Parenchyma
• Arteriosclerotic plaque or thrombi
• Carotid bruit, funduscopic ab.,enlarged cham

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Picks disease

• Atrophy of Frontotemporal
• Picks body
• Male gt Female
• Kluver-Bucy syndrome

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Creutfeldt-Jacob Disease

• Prion Slow progressive
• Spongioform degeneration of brain S inflammatory
  response
• Incubation 1-2 yrs to 8-16 yrs
• Tremor, Ataxia, Myoclonus, dementia

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Huntingtons disease

• Subcortical dementia
• Impair. Motor gt Language
• Difficult in Complicated Task
• Choreoathetoid movement
• Depression Psychosis gt in DAT

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HIV-Related Dementia

• 14 of Pt c HIV
• Head Trauma-Related Dementia
• After head trauma

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Diagnosis

• Dementia of Alzheimers type (DAT)
• Vascular Dementia
• Dementia due to other general medical cond.
• Substance induced persisting dementia

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Clinical Feature

• Memory Impairment Recent before Remote
• Orientation normal until increase memory
  impairment , normal conciousness
• Language Impairment esp cortical dementia

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Personality Change introvert, social withdraw,
suspiciousness, irritable frontaltemporal.Psyc
hosis -20-30 -DAT hallucination 30
delusion 40
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Others -Psychiatric depression
anxiety -Neurological aphasia, apraxia,
agnosia, seizure -Sundowning syn. drowsiness,
confusion, ataxia
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Differential Diagnosis

• DAT Vascular dementia
• DAT Picks disease
• Delirium
• Depression
• Normal aging
• Schizophrenia
• Factitious disorders

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Laboratory Investigation

• Comprehensive workup
• -PE, NS
• -MSE, MMSE
• -Blood Urine for drug,substances
• -Chest X-ray

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-Physiological workup -EKG -Neuro.
Workup CT, MRI SPECT LP EEG -Neuropsy
chological Testing
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Treatment

• Psychopharmacotherapy
• Memory Enhancement Drug
• Centrally Acting Cholinesterase
• Family Management
• Psychotherapy

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Psychopharmacotherapy

• AnxietyShort-acting Benzodiazepine
• Insomnia Chooses BZD depend on Initial, middle,
  terminal
• Agitation,Aggression, Violent
• -Neuroleptics Drug of choice, haloperidol
  0.5-2 mg IM

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-Nonneuroleptics Propanolol, Carbamazepine,
Fluoxetine, Trazodone, Lithium-Benzodiazepine.De
pression Antidepressants.Mania Lithium,
Carbamazepine, Valproate. Psychoses high
potency antipsychotics. Sexual aggression
medroxy progesterone
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Memory Enhancement drug

• Artherosclerosis
• Cerebral vasodilator, Anticoagulant
• Neuropeptide , Cerebral metabolic enhancer
• Drug associated with cholinergic system

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Centrally Acting Cholinesterase Inhibitor

• Tacrine
• Donepezil(Aricept)
• No evidence for prevent the progressive neuronal
  degeneration

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Family Management

• Suggest planning Care for Pt
• Understanding Accept
• Environmental Manipulation
• Supportive Group for Fm. Member
• Individual Psych. For Fm. Member

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Psychotherapy

• Supportive Psychotherapy Direct Tech.
• Coping Defense Mechanism

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Course and Prognosis

• Course 5-10 yrs , deterioration
• DAT1-20 (8) yrs
• Psychosocial factor low IQ, anxiety, depression
  asso. Increased symptom

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Amnestic Disorders

• Only memory impairment
• Normal other cognitive function conciousness

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Etiology

• Diencephalon dorsomedial midline nuclei of
  thalamus
• Midtemporal lobe hippocampus, mamillary body,
  amygdala
• Usually involved bilateral
• Frontal lobe confabulation apathy

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Diagnosis

• Cerebrovascular disease hippocampus
• Multiple sclerosis plaque in temporal lobe,
  diencephalon
• Korsakoffs syn Thiamine deficiency
• Alcoholic Blackout
• ECT

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Differential Diagnosis

• Dementia Delirium
• Normal Aging
• Dissociative disorders
• Facticious disorders

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Treatment

• Remove causes
• Other Tx. similar to dementia

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Mental dis due to gen. Med . cond

• Catatonic dis. Due to gen.med.cond
• Personality change. Due to gen.med.cond
• Mental dis. due to NOS

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Degenerative disease

• Involves basal ganglia asso movement dis.
  depression
• Parkinsons dissubstantial nigra
• Huntingtons dis caudate nucleus autoso
  dominant
• Wilsons disease autoso recessive , lenticular

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Epilepsy

• 30-50 asso Psychiatric disorders
• The most common Personality change

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Classification

• Generalized Seizure
• -Generalized tonic-clonic seizure
• -Absence
• Partial Seizure
• -Complex partial seizure

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Complex Partial Seizure

• Pre-ictal autonomic sensation, cognitive
  sensation, affective state , automatism
• Ictal loss of conciousness

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Interictal

• Personality disturbance
• -Sexual Beh.
• -Viscosity of personality
• -Religiosity
• Psychoses hallucination paranoid delusion

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Violence foci temporal , frontal.Mood
disorders depression, mania Treatment-Drug
of choice for CPs Valproate , Carbamazepine-Fm.
Therapy-Individual Psychotherpy-Group
psychotherapy