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Delirium, Depression and Dementia

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Title: Delirium, Depression and Dementia


1
Delirium, Depression and Dementia
  • ??????????????????????? ????????????
  • ????????????????????????
  • ??????????????????
  • ???????????????????????????????

2
Contents
  • Clinical feature and diagnosis
  • Delirium
  • Depression
  • Dementia
  • Differential diagnosis of DDD

3
Delirium
  • ??????? acute, transient organic mental
    syndrome characterized by a global disorder of
    cognition and attention, a reduced level of
    consciousness, abnormality increased or reduced
    psychomotor activity, and a disturbed sleep wake
    cycle

4
  • ??????????????? 2 ??? ICU
  • ?????????????? ???? 85 ??
  • third day post-op for
  • total hip replacement ????????????
  • ?????? ????????????????????????????????????

5
PE T 36.5OC, BP 140/90 mmHg, P 96/min, R
16/min ????????????????? ??????????????????
????? 3 ??????????? ??????????????????????????????
? ???????? ???????????????????????????????????????
?? ????????????? ???????????????? ????
Dx ? Mx ?
6
Diagnostic Criteria for Delirium
1 Disturbance of consciousness 2 A change in
cognition 3 Brief period and fluctuation
during the course of the day
7
Diagnostic Criteria for Delirium
4 Caused by a. a general medical condition b. a
substance intoxication or side effect
c. a substance withdrawal d. multiple factors
8
Disturbance of conscious alter in
  • awareness
  • alert
  • attention

9
  • Disturbance in cognition
  • What does it mean ?

10
Cognitive function
- memory - perceiving - reasoning -
judgment - imagining - thinking
11
Disturbance of cognition
1. Perceptual disturbance 2. Disorientation 3.
Memory disturbance
12
Perceptual disturbance
  • illusion
  • delusion
  • hallucination

13
Abnormal of psychomotor activities
1. Hyperactive psychomotor activities 2.
Hypoactive psychomotor activities 3. Mixed type
14
Factors Predisposing to Delirium
  • Advance age
  • Recent surgical procedure
  • Trauma (including burns and hip
  • fractures)
  • Substance or drug use to dependence

15
Factors Predisposing to Delirium
  • Low serum albumin level
  • Proteinuria

16
Factors Predisposing to Delirium
  • Medical condition
  • CNS disease esp. dementia
  • others are
  • stroke
  • seizure
  • head injury
  • metastasis to brain
  • primary brain tumor

17
Factors Predisposing to Delirium
  • Cardiopulmonary problems eg.
  • myocardial infarction
  • congestive heart failure
  • hypertensive encephalopathy
  • pulmonary embolus
  • pneumonia
  • hypoxia from any cardiopulmonary
    condition

18
Factors Predisposing to Delirium
  • Metabolic disturbance eg.
  • electrolyte abnormalities
  • severe vitamin deficiency or malnutrition
  • fluid imbalances
  • hyperglycemia or hypoglycemia
  • hyperthyroidism or hypothyroidism

19
Factors Predisposing to Delirium
  • Genitourinary problems
  • uremia
  • urinary tract infection
  • severe urinary retention
  • Infections potentially all infection

20
Factors Predisposing to Delirium
  • Gestrointestinal
  • Hepatic encephalopathy
  • Severe fecal impaction
  • Rheumatologic
  • Vasculitis

21
Primary prevention of delirium in the elderly
  • minimized drugs prescribed for the elderly
  • avoid more than one drug with
  • ant cholinergic effect
  • identify who high risk for delirium

22
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Cardio-vascular conditions Antiarrhythmics Antihypertensives Cardiac glycosides Coronary vasodilartors Procainamide, propranolol quinidine, Clonidine, methyldopa, reserpine Digitalis Nitrates
23
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Gastro-intestinal conditions Antidiarrheals Antinauseants Antispasmotics Atropine, belladonna, hyoscyamine, scopolamine Cimetidine, cyclizine, phenothiazines Methanthelene, propantheline
24
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Musculo-skeletal conditions Anti-inflammatory agents Muscle relaxants Corticosteroids, indomethacin, salicylates Carisoprodol, diazepam
25
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Neurologic- psychiatric conditions Anticonvulsants Antiparkinsonism agents Barbiturates, carbamazepine, diazepam, phenytoin Amantadine, benztropine, levopoda, trihexyphenidyl
26
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Neurologic- psychiatric conditions Hypnotics and sedatives Barbiturates, belladonna alkaloids, bromides, chloral hydrate, glutethimide Benzodiazepines,
27
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Neurologic- psychiatric conditions Psychotropics Benzodiazepines, hydroxyzines, lithium salts, meprobamate, monoamine oxidase inhibitors, neuroleptics, tricyclic antidepressants
28
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Respiratory-allergic conditions Antihistamines Brompheniramine, chlorpheniramine, cyproheptadine, diphenhydramine
29
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Respiratory-allergic conditions Antitussives Decongestants and expectorants Opiates, synthetic narcotics Phenylephrine, phenylpropanolamine, potassium preparations
30
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Miscellaneous conditions Analgesics Anaesthetics Dextropropoxyphene, opiates, phenacetin, salicylates, synthetic narcotics Lidocaine, methohexital, methoxyflurane
31
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Miscellaneous conditions Antidiabetic agents Antineoplastics Insulin, oral hypoglycemics Corticosteroids, mitomycin, procarbazine
32
Common Medications causingDelirium in the Elderly
Disorder Medication Common examples
Miscellaneous conditions Antituberculosis agents Antibiotics Isoniazid, rifampin Ciprofloxacin, penicillin
33
Depression
  • Detinstion
  • DSM-IV
  • At least five of the following nine symptoms

34
Depression
  • ??????
  • A depressed mood or lose of interest / pleasure
  • Present most of the day, nearly everyday
  • ?????????????????? 2 ???????

35
Depression
  • Depressed mood
  • Loss of interests / pleasure
  • Change in sleep
  • Change in appetite or weight
  • Change in psychomotor activity

36
Depression
  • Loss of energy
  • Trouble concentration
  • Thoughts of worthlessness of guilt
  • Thoughts about death or suicide

37
Depression-defined
  • sleep disturbances
  • loss of interest
  • feelings of guilt
  • decreased energy

38
Depression-defined
  • concentration/memory problem
  • appetite/weight changes
  • psychomotor changes (agitation/retardation)
  • thoughts of death or suicide

39
Pharmacological Causes of Depression
  • Cardiac and hypertensive drugs
  • Reserpine , methyldopa , propanolol
  • Sedatives and hypnotics
  • Barbiturates , benzodiazepines
  • Steroids and hormones
  • Corticosteroid , estrogen , oral contraceptives

39
40
Pharmacological Causes of Depression
  • Psychotropic drugs
  • Neurological agents
  • Levodopa , amantadine
  • Analgesics and anti-inflamatory drugs
  • Antibacterial and antifungal drugs
  • Antineoplastic drugs
  • Vincristine , vinblastine

40
41
Pharmacological Causes of Depression
  • Stimulants and appetite suppressants
  • amphetamine
  • Miscellaneous drugs
  • cimetidine

41
42
Dementia
43
Criteria for diagnosis of dementia (DSM IV)
  • Development of multiple cognitive
  • deficits including memory impairment
  • and at least one of the following
  • aphasia (deterioration in language)
  • apraxia (impaired ability to execute
  • motor abilities, sensory functions
  • and comprehension of the task)

44
Criteria for diagnosis of dementia (DSM IV)
  • agnosia (failure to recognise and
  • identify objects despite intact
  • sensory functions)
  • disturbance in executive functioning
  • (ability to think abstractly, to plan,
  • sequence, initiate, monitor and
  • stop complex behaviour)

45
Must be sufficiently severe to cause impairment
in occupation and social functioning, and
represent a decline from previous higher level
of functioning, should not be made during the
course of delirium
46
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46
47
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47
48
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49
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49
50
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50
51
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51
52
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52
53
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53
54
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54
55
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55
56
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56
57
????????????? ?? 1???????????????????????????
  • ??????????????? 12 ????
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  • ??????? (gt 10 ??)
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57
58
????????????????? 12
  • ???
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58
59
???????????????????????????????
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59
60
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  • ???????????????????????????/????
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  • ??????
  • ?????

60
61
???????????????????????????????
  • 8. ??????????????????????????????
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61
62
????????????????????? 1 ?? 10
  • ???????????????????????? (??? / ???)
  • ???????????? 12
  • ?????????????????? ??????????????????????????
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62
63
Differential diagnosis of DDD
  • Onset
  • Clinical features
  • Associated symptoms

64
?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Onset Sudden Insidious Insidious
Course over 24 h Fluctuating, with nocturnal exacerbation Stable Stable
65
?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Consciousness Reduced Clear Clear
Attention Globally disordered Normal, except in severe cases May be disordered
Cognition Globally disordered Globally impaired May be selectively impaired memory
66
?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Hallucinations Usually visual or visual and auditory Often absent Often absent Except in psychotic depression-rare
Delusions Fleeting, poorly systematized Often absent Often absent
67
?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Orientation Usually impaired, at least for a time Often impaired Normal
68
?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Psychomotor activity Increased, reduced, or shifting unpredictably Often normal Varies from psychomotor retardation to hyperactivity depending on the type of depression
69
?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Speech Often incoherent, show or rapid Patient has difficulty finding words perseveration Normal, show, or rapid
Involuntary movements Often asterixis or coarse tremor Often absent Usually absent, some fine tremor
70
?????????????????????? Delirium, Dementia ???
Depression
Characteristic Delirium Dementia Depression
Physical illness or drug toxicity One or both are present Often absent, especially in senile dementia of the Alzheimer,s type Usually multiple complaints, poly pharmacy
71
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