cognitive disorders
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Cognitive Disorders . YASER ALHUTHAIL, MD ASSOCIATE PROFESSOR PSYCHOSOMATIC MEDICINE. Disruption in one or more of the cognitive domains, and are also frequently complicated by behavioral symptoms. - PowerPoint PPT PresentationTRANSCRIPT
Cognitive Disorders
YASER ALHUTHAIL, MDASSOCIATE PROFESSOR
PSYCHOSOMATIC MEDICINE
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
DeliriumAcute 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 inpatients30 percent of patients in intensive care units and 40 to 50 percent of patients who are recovering from
surgery for hip fracturesUnderrecognized and undertreated !!
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
Risk FactorsExtremes of age Number of medications takenPreexisting brain damage (e.g., dementia,
cerebrovascular disease, tumor)History of deliriumAlcohol dependenceDiabetesCancerSensory impairment Malnutrition
Central nervous system disorder
Seizure (postictal, nonconvulsive status, status)MigraineHead trauma, brain tumor, subarachnoid hemorrhage, subdural, epidural hematoma, abscess, intracerebral hemorrhage, cerebellar hemorrhage, nonhemorrhagic stroke, transient ischemia
Metabolic disorder Electrolyte abnormalitiesDiabetes, hypoglycemia, hyperglycemia, or insulin resistance
Systemic illness Infection (e.g., sepsis, malaria, erysipelas, viral, plague, Lyme disease, syphilis, or abscess)TraumaChange in fluid status (dehydration or volume overload)Nutritional deficiencyBurnsUncontrolled pain
Medications Pain medications Antibiotics, antivirals, and antifungalsSteroidsAnesthesiaCardiac medicationsAntihypertensivesAntineoplastic agentsAnticholinergic agents
Cardiac Cardiac failure, arrhythmia, myocardial infarction, cardiac assist device, cardiac surgery
Pulmonary Chronic obstructive pulmonary disease, hypoxia, SIADH, acid base disturbance
Endocrine Adrenal crisis or adrenal failure, thyroid abnormality, parathyroid abnormality
Hematological Anemia, leukemia, blood dyscrasia, stem cell transplant
Renal Renal failure, uremia, SIADHHepatic Hepatitis, cirrhosis, hepatic failure
Neoplasm Neoplasm (primary brain, metastases, paraneoplastic syndrome)
Drugs of abuse
Intoxication and withdrawal
Toxins Intoxication and withdrawalHeavy metals and aluminum
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.
Diagnosis and Clinical FeaturesThe core features of delirium include:Altered consciousnessAltered attention, which can include diminished ability
to focus, sustain, or shift attentionImpairment in other cognitive functions, which can
manifest as disorientation and decreased memoryFluctuations in severity and other clinical
manifestations during the course of the day, sometimes worse at night (sundowning)
Disorganization of thought processesPerceptual disturbancesPsychomotor hyperactivity and hypoactivity
The major neurotransmitter hypothesized to be involved in delirium is acetylcholine
Anticholinergic activity
Laboratory Workup of the Patient with DeliriumBlood 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
Differential DiagnosisDementia DepressionSchizophrenia Course and Prognosis
The symptoms of delirium usually persist as long as the causally relevant factors are present
Delirium is a poor prognostic sign
TreatmentThe primary goal is to treat the underlying causeThe other important goal of treatment is to provide
physical, sensory, and environmental support
Pharmacotherapyhaloperidol risperidone, clozapine, olanzapine, quetiapine
DementiaGlobal 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 behaviorCan 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
Possible Etiologies of Dementia Degenerative dementias
Alzheimer's disease Frontotemporal dementias (e.g., Pick's disease) Parkinson's disease Lewy body dementia Miscellaneous Huntington's disease Wilson's disease Psychiatric Pseudodementia of depression Cognitive decline in late-life schizophrenia Physiologic Normal pressure hydrocephalus Metabolic 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 hematomaInfection Prion 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
Dementia of the Alzheimer's TypeThe 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
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.
Diagnosis and Clinical FeaturesThe diagnosis of dementia is based on the clinical
examinationMemory 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
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
Diagnostic Criteria for Dementia of the Alzheimer's TypeA-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 conditionsE-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
Diagnostic Criteria for Vascular Dementia A.The development of multiple cognitive deficits manifested by both
A. memory impairment (impaired ability to learn new information or to recall previously learned information)
B. one (or more) of the following cognitive disturbances: A. aphasia (language disturbance) B. apraxia (impaired ability to carry out motor activities despite intact motor
function) C. agnosia (failure to recognize or identify objects despite intact sensory
function) D. 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.Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance. D.The deficits do not occur exclusively during the course of a delirium.
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 DementiaAlcohol-Induced Persisting Dementia
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 DiagnosisDeliriumDepression (pseudodementia )SchizophreniaNormal Aging
Feature Dementia DeliriumOnset Slow Rapid
Duration Months to years Hours to weeks
Attention Preserved Fluctuates
Memory Impaired remote memory Impaired recent and immediate memory
Speech Word-finding difficulty Incoherent (slow or rapid)Sleep cycle Fragmented sleep Frequent disruption (e.g.,
day–night reversal)
Thoughts Impoverished Disorganized
Awareness Unchanged Reduced
Alertness Usually normal Hypervigilant or reduced vigilance
TreatmentThe 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
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