Delirium, Dementia, and Other Cognitive Mental Disorders

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Delirium, Dementia, and Other Cognitive Mental
Disorders

• Overview and Classification
• Delirium an acute, usually reversible brain
  disorder characterized by clouding of the
  consciousness and a reduced ability to focus and
  maintain attention
• Types of Delirium
• a. Delirium due to

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b. Substanceintoxication delirium c.
Substance-withdrawal delirium d. Delirium due
to multiple etiologies e. Delirium not
otherwise specified (NOS)B. Dementia a
chronic, irreversible brain disorder
characterized by impairments of memory, abstract
thinking, and judgment, as well as changes in
personality
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1. Chronic development of multiple
cognitive deficits manifested by memory and one
or more of the following cognitive disturbances
a.Aphasia, a loss of the ability to understand
or use language b. Apraxia, an inability to
carry out skilled and purposeful movement
inability to use objects properly c. Agnosia,
an inability to recognize familiar situations,
people, or stimulid. Disturbance in executive
functioning (i.e., planning, organizing,
sequencing, and abstracting)
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Types of dementia (APA, 2000)

• Dementia of the Alzheimers type (DAT)
• Vascular dementia (formerly multi-infarct
  dementia)
• Dementia due to other general medical conditions
  .
• Substance-induced persisting dementia .
• Dementia due to multiple etiologies T
• Dementia not otherwise specified (NOS)

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Amnestic disorders

• Development of memory impairment characterized by
  inability to learn new information or inability
  to recall previously learned information
• Can be transient (lasting for l month or less) or
  chronic (lasting for more 1 month or less
• Causes significant impairment in social or
  occupational functioning and sents a significant
  decline from a previous level of functioning

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Types of anmestic disorders (APA, 2000)

• Anmestic disorder due to . . . (indicate the
  general medical condition)
• Substance-induced persisting amnestic disorder
• Amnestic disorder not otherwise specified (NOS)

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Other cognitive disorders (APA, 2000)

• Cognitive dysfunction presumed to be caused by a
  direct physiological effect of a general medical
  condition that does not meet criteria for any of
  the specific delirium, dementia, or arnnestic
  disorders previously listed
• Cognitive disorders not otherwise specified
  (examples)
• a. Mild neurotic disorder
• b. Postconcussional disorder

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Etiology

• A. Delirium, dementia, and other cognitive
  disorders are caused by multiple etiologies that
  interfere with cerebral blood flow Q
• B. General medical conditions causing an
  interference of necessary blood supply and
  therefore nutrients (e. g., oxygen, glucose,
  vitamins) to the brain can result in cognitive
  disorders

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• Decreased cerebral blood flow cardiac
  arrhythmias or arrest, shock, hypertension,
  congestive heart failure, (CHF) cerebrovascular
  attack (CVA), transient ischemic attacks (TIA),
  pulmonary embolism (PE), systemic lupus
  erythernatosus (SLE)
• Brain hypoxia chronic obstructive pulmonary
  disease (COPD), asthma, emphysema, anemia, carbon
  monoxide poisoning
• Vitamin deficiency alcoholism, pernicious
  anemia, Wernickes disease, Korsakoffs syndrome
• Infections sepsis, subacute bacterial
  endocarditis, pneumonia, urinary tract
  infections, AIDS dementia complex (ADC)
• Endocrine and metabolic disorders uncontrolled
  diabetes mellitus, insulin shock, hypothyroidism,
  adrenal insufficiency electrolyte imbalance,
  acidosis, alkalosis
• Hepatic and renal failure hepatic
  encephalopathy end-stage renal disease
• Trauma and tumors traumatic brain injury (TBI),
  carcinomas

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• C. Substances causing toxicity to the brain
  either by exposure to, high doses to Pass
  withdrawal from the substance can lead to
  cognitive disorders
• 1. Ingestion of medications such as
  anticonvulsants, neuroleptics, anxiolytics,, the
  emergency antidepressants, cardiovascular
  medications, antineoplastics, and hormones or
  exposure to lead, aluminum or other heavy metals
• 2. Drugs commonly abused such as alcohol,
  carmabis, cocaine, hallucinogens, and
  anxiolytics, or opioids
• 3. Termination or reduction in use of long-term,
  high-dose substances such as alcohol, sedatives,
  hypnotics, or anxiolytics

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• D. Genetic or viral diseases can cause
  pathological changes or biochemical imbalances in
  the brain that interfere with cerebral blood
  flow.
• 1. Dementia of the Alzheimers type specific
  cause is unknown but theories include reduction
  in brain acetylcholine, accumulation of aluminum
  in the immune system alterations, head trauma,
  and genetic factors such as Down syndrome
• 2. Parkinsons disease caused by a loss of nerve
  cells in the substantia nigra in the the basal
  ganglia
• 3. Huntingtons disease transmitted as a
  mendelian dominant gene, and occurs in the areas
  of the basal ganglia and the cerebral cortex
• 4. Picks disease caused by atrophy in the
  frontal and temporal lobes of the brain
• 5. Creutzfeldt-Jakob disease caused by a
  transmissable virus

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III. Assessment

• A. Delirium has a sudden onset and an
  identifiable cause
• 1. A positive history for delirium includes
• A thorough medical evaluation revealing abnormal
  lab results K
• An electroencephalogram (EEG) confirming
  cerebral dysfunction
• Identification of the underlying cause of
  delirium
• Ruling out other reasons for delirium
  (depression, anxiety, dementia, or personality
  disorder)

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• 2. Presenting signs and symptoms _
• Fluctuating levels of consciousness (i.e.,
  alternating periods of coherence with periods of
  confusion) disorientation that worsens at the
  end of the day, usually referred to as sundown
  syndrome
• Alternating patterns of hyperactivity (typical
  of drug withdrawal) to hypoactivity (typical of
  metabolic imbalance)
• Hyperactive behaviors
• l) Rambling, bizarre, incoherent, rapid,
  pressured, or loud speech A
• 2) Restlessness, picking at clothes or bed
  linen, irritability, euphoria

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Dementia is a progressive disease and symptoms
can be divided into three stages

• Stage l (typically lasts l to 3 years)
• Difficulty performing complex tasks related to a
  decline in recent memory forgetfulness, missed
  appointments clients often recognize and are
  frightened by their confusion
• Declining personal appearance, inappropriate
  dress for weather
• Lack of spontaneity in verbal and nonverbal
  communication
• Disoriented to time but can remember people and
  places Decreased concentration, increased
  distractibility impaired judgment

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Stage 2 (lasting approximately 2 to l0 years)

1. Poor impulse control with frequent outbursts and
   tantrums labile emotions catastrophic
   reactions or overreactions to minor stresses
   occur frequently in demented clients
2. Wandering or aggressive behavior, hallucinations,
   delusions
3. Aphasia, which begins with the inability to find
   words and eventually limits the person to as few
   as six words
4. Hyperorality, the need to taste, chew, and
   examine any object small enough to be placed in
   the mouth
5. Perseveration phenomena, repetitive behaviors
   such as lip licking, finger tapping, pacing, or
   echolalia
6. Confabulation, the filling in of memory gaps with
   imaginary information in an attempt to distract
   others from observing the deficit
7. Agraphia, the inability to read or write
8. Agnosia (the inability to recognize familiar
   situations, people, or stimuli) can occur as
   auditory, visual, or tactile impairments
9. Alexia, or visual agnosia, is the inability to
   identify an object or its use by sight such as a
   toothbrush or telephone

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Stage 3 (lasting 8 to 10 years before death
occurs)

1. Kluver-Bucy syndrome develops, which includes the
   continuation of hyperorality and the development
   of binge eating
2. Hyperetamorphosis, the need to compulsively touch
   and examine every object in the environment
3. Progressive deterioration in motor ability
   including inability to walk, sit up, or even to
   smile
4. Progressive decrease in response to
   environmental stimuli leading to total
   increasingly confused nonresponsiveness or
   vegetative state
5. Severe decline in cognitive function, losing
   ability to recognize others
6. May scream spontaneously or be able to say only
   one word frequently becomes mute

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Planning and Implementation

• Specific treatment modalities I
• a. Psychopharmacology I
• a. Cholinesterase inhibitors can slow down
  progression of mild to moderate in
• dementia
• a. (Cognex) effects can be seen in 6 weeks
• b. Donepezil (Aricept), slows deterioration of
  mild to moderate dementia I
• b. Management of anxiety, aggression, and
  agitation and has difficulty
• a. Lorazepam (Ativan) 0.5 mg p.o.
• b. Trazodone (Desyrel) 25 to 500 mg/day can
  decrease agitation and ag
• gression without decreasing cognitive
  performance I
• c. Buspirone (Buspar) 10 to 60 mg/day not
  sedating and has fewer side effects, preferable
  to benzodiazepines

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Management of depression

• l) Selective serotonin reuptake inhibitors
  (SSRIs) are better tolerated in older adults than
  tricyclic antidepressants (TCAs), which have high
  anticholinergic and cardiac side effects
• 2) Common SSRIs include fluoxetine (Prozac),
  paroxetine (Paxil), sertraline (Zoloft), and
  nefazodone (Serzone)
• Management of psychotic features (hallucinations
  and delusions)
• Atypical antipsychotic agents are more effective
  in managing positive and negative symptoms
  without extra-pyramidal side effects
• Common atypical antipsychotics include
  olanzapine (Zyprexa), quetiapine (Seroquel), and
  risperidone (Risperdal)
• Use of haloperidol (Haldol), a potent
  neuroleptic, is controversial and
• has been known to cause tardive dyskinesia in
  older adults small doses (0.5 mg) may help to
  regulate sleep

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Behavior modification . .

• Use of physical restraints should be carefully
  evaluated and used as a last resort sensor
  devices that alert staff when a client is out of
  bed or going outside should be installed to
  manage risks to safety from wandering behavior
• Reality orientation in the form of labels on
  objects in the environment, and
• large print calendars and clocks can be gentle
  reminders of information discuss meaningful
  topics such as significant life events, family
  work, or hobbies to promote the persons
  identity avoid arguing with or convincing
  persons with dementia about actual reality
  communicate in a calm, quiet voice with simple,
  clear instructions
• Group and individual therapies

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• Reminiscence or life review therapy facilitate
  discussion of topics dealing with specific life
  transitions such as childhood, adolescence,
  marriage, childbearing, grandparenthood, and
  retirement pets, music, and special foods can be
  used to evoke memories from clients past share
  positive and negative feelings
• Validation therapy interacting with clients on a
  topic they initiate, in a place and time where
  they feel most secure reflecting the underlying
  feelings of concern (e. g., "You miss your
  husband. You must be feeling lonely here. Reality
  orientation is geared toward the person and place
  rather than to the time
• Milieu therapy
• Special care units (SCU) environmentally
  designed and specifically programmed to serve
  needs of residents with Alzheimers disease and
  related dementias

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• Design components of SCU
• Safe, secure, specially adapted physical
  environment to accommodate wandering behavior
  inside and outside (circular design, secure
  walkway and patio)

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The following interventions should be
incorporated into the care of confused clients

• Interventions Provide simple, clear
  instructions focusing on one task at a time.
• Speak slowly and in a face-to-face position when
  communicating with clients known to have a
  hearing loss. Shouting causes distortion of
  highpitched sounds and can frighten the client.
• Allow the client to have familiar objects around
  him or her to maintain reality orientation and
  enhance self-worth and dignity.
• Discuss topics that are meaningful to the client
  such as significant life events, family, work,
  hobbies, and pets.
• Refrain from arguing or convincing client that
  delusions are not real.
• Provide a simple, structured environment with
  consistent personnel to minimize confusion and
  provide a sense of security and stability in the
  clients environment.
• Encourage reminiscence and discussion of life
  review by sharing picture albums.
• Discuss family traditions and holidays, memories
  of school, courtship, dating rituals, favorite
  pets, and other past events.
• Encourage family/caregivers to express feelings,
  particularly frustration and anger.
• Provide a list of community resources and support
  groups available to assist in decreasing dice to
  Pass stress and role strain for the
  family/caregiver.
• Personalized rooms with own furniture and
  familiar belongings

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• THANK YOU SO MUCH, SEE YOU
• AT THE MENTAL HOSPITAL