Delirium, Dementia and Amnestic and Other Cognitive Disorders

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Delirium, Dementia and Amnestic and Other
Cognitive Disorders

• RCS 6931
• Steven R. Pruett, Ph.D.
• 6/4/07

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Cognition

• What is Cognition?
• Information processing
• Storage, Retrieval and Manipulation of
  information
• What is a Cognition Disorder?
• Cognitive Disorders are abnormalities of thinking
  memory that are related to brain dysfunction
• (either permanent or temporary)

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Symptoms Terms

• Amnesia Loss of memory
• Retrograde
• Antergrade
• Aphasia Disturbance of language
• Apraxia Inability to perform motor behavior
• Agnosia Inability to recognize familiar objects
• Loss of executive functioning Difficulty in
  planning, organizing, sequencing, or abstacting
  info.
• Confusion an inexact and general term for slowed
  thinking, loss of memory or disorientation.
• Functional Cant find a physiological, chemical
  or organic reason for a mental disorder.

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Delirium Symptoms

• Change in the way the brain is working, but is
  usually due to an illness elsewhere outside of
  CNS. Symptoms are
• Reduced clarity of awareness of environment
• Some sort of cognitive deficit
• Language
• Memory
• Orientation
• Perception

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Delirium Symptoms (cont)

• Other disturbances
• Sleep-Wake cycle
• Psychomotor activity/behavior
• Mood
• Reasoning

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Delirium - Course

• Sudden onset
• Fluctuating intensity
• Many patients are lucid in AM and worse at night
  (AKA sundowning)
• Usually last a week or less then resolve after
  underlying cause is treated.
• Sometimes it resolves into a dementia or amnestic
  disorder.
• Patients may not recall some events after a
  delirium
• dreamlike

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Delirium 293.0

• Can be misdiagnosed as
• Psychosis
• Depression
• Mania
• Hysteria
• Personality Disorder
• It is the most common of cognitive disorders
  highest incidence of all mental disorders
• ½ of all hospitalized elderly patients may become
  delirious.
• More common in children and elderly not so
  common among young adults and middle aged.

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Delirium 293.0

• Since it is caused by a disease that can lead to
  dementia or death delirium is considered an
  emergency.
• If you suspect a delirium it is vital that a
  medical examination/consultation be conducted
  immediately
• Dx of delirium is often a result of a bedside
  evaluation (hard to do neuropsych testing on
  someone whos delirious).
• Diagnostic criteria
• Morrison p. 18 DSM-IV-TR p. 143
• Treatment Treat underlying cause right away

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Substance-Induced Delirium

• Different criteria for Intoxication and
  Withdrawal
• Substance Intoxication
• Diagnostic criteria Morrison p. 21, DSM-IV p. 145
• Occurs with substances such as
• ETOH and other drugs,
• Chemicals
• Prescription Medications
• Elderly ( Children) are particularly vulnerable
• ETOH 291.0
• All others 292.81

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Substance Withdrawal Delirium

• ETOH
• ETOH delirium tremens (DTs)
• Symptoms
• Agitation
• Tremor
• Disorientation
• If left untreated 15 die
• Anesthesia
• Other drugs
• Other Chemicals
• Diagnostic Criteria
• Morrison p. 22, DSM-IV p. 146.
• Same as Substance Intoxication Delirium.

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Other Deliriums

• Multiple etiologies
• Several reasons why delirium has developed
• Two distinct codes
• Delirium NOS
• 780.09
• Etiology not yet established
• Sensory deprivation

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Dementias

• Dementia means loss
• Must be a decline from a previous level of
  functioning.
• Mental retardation by itself is not a dementia.
• Howeverpeople with mental retardation can
  develop a dementia
• Downs syndrome Alzheimers
• Memory loss
• All dementias include some type of memory loss
• Recent
• Remote
• Sense of self usually preserved
• Other cognitive deficits
• Agnosia
• Aphasia
• Apraxia
• Loss of Executive Functioning

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Dementia

• All patients with Dementia must have one of the
  three As
• Agnosia
• Aphasia or
• Apraxia
• These may occur later in the dementia
• Cannot be diagnosed if the patient only has
  delirium
• However the two conditions can exist
  simultaneously
• Loss of ability to think clearly brings on a
  functional impairment.

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Dementia

• Onset is usually gradual
• Early symptoms
• Loss of interest in work/leisure activities
• Change in long-standing personality traits
• Loss of judgment impulse control
• Loss of social graces
• Crude jokes
• Hygiene
• Later symptoms
• Vulnerable to psychosocial stresses
• Paranoia
• Shoplifting
• Listmaking
• Agitation
• Complete unawareness of people and surroundings

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Dementia

• Some types are hereditary
• Eg (Alzheimer's, Huntington's)
• Other types are not
• HIV/AIDS, endocrine conditions, anoxia, infection
  disorders, Creutzfelt-Jakob disease, vitamin
  deficiencies
• Diagnosis of dementia demands a medical and
  neurological evaluation to determine causation
  and to intervene with treatment when it is
  possible.

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Dementia

• Many dementias can be diagnosed by biological
  changes
• E.g. Huntingtons, MS, AIDS
• Some cannot and can only be inferred based on
  demonstrated pathology.
• E.g. Alzheimers, Picks disease

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Alzheimers Type 294.1x

• Most common cause of dementia
• ½ of all cases
• Effects 3 of people over 65 years of age and
  increases steadily with years past 65.
• Accounts for twice as many cases as Vascular
  dementia

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Alzheimers

• Many individuals in nursing facilities have AD
• Large portion of individuals with Downs syndrome
  over age 40 have AD
• Patients with early onset AD are likely to have
  relatives with same condition.

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Alzheimers

• First signs
• Change of personality
• Obsessional
• Secretive
• Sexually active
• Apathy
• Emotional lability
• Loss of sense of humor
• Loss of memory
• Short-term (immediate memory)
• Loss of executive functioning
• Due to damage to frontal lobes
• Aphasia
• Trouble finding words
• No longer being able to use complex sentences

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Alzheimers

• Typically an Alzheimers patient will live 6-8
  years after disease begins.
• 3 stages
• 1-3 years of growing forgetfulness
• 2-3 years of increasing disorientation, loss of
  language skills and inappropriate behaviors
• Final period disorientation of the person,
  complete loss of self-care.
• Usually there is a complete loss of insight

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Changes to Brain Anatomy

• Diminished blood flow
• Neurofibrillary Tangles
• Neuritic Plaques
• Degeneration of hippocampus, cerebral cortex,
  hypothalamus, and brain stem

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Plaques and Tangles
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Normal vs AD Brain
Alzheimers brain
Normal brain
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Alzheimers
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AD Prognosis

• Alzheimers has a slow progressive decline. Meds
  can slow the progression, NOT halt it.

Function
Time
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Alzheimers

• Diagnostic criteria
• Morrison p. 31 32 DSM-IV p. 157-158
• Treatment
• Pharmacological
• cholinesterase inhibitors
• prevent the breakdown of acetylcholine, a
  chemical messenger in the brain that is important
  for memory and other thinking skills
• Memantine
• For moderate to severe AD. Mematine works by
  regulating the activity of glutamate, one of the
  brains specialized messenger chemicals involved
  in information processing, storage and retrieval
• Vitamin E
• May reduce oxidative stress on neurons

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Alzheimers

• Behavioral interventions
• identifying the behavior
• understanding its cause, and
• adapting the caregiving environment to remedy the
  situation.
• Instead of being confrontational or angry
• simplify the environment
• simplify tasks and routines
• allow adequate rest between stimulating events
• use labels to cue or remind the person
• equip doors and gates with safety locks
• remove guns
• reduce risk of fires with extra smoke alarms and
  control access to the stove
• use lighting to reduce confusion and restlessness
  at night

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Vascular Dementia 290.4x

• About 20 of all dementias are vascular in
  origin.
• AKA multi-infarct dementia.
• Series of small strokes
• Likely to co-occur with diabetes or hypertension

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Vascular Dementia

• Diagnostic criteria
• Morrison p. 35-36, DSM-IV p. 161.
• Treatment
• Care for medical condition (diabetes,
  hypertension)
• Behavioral and psychotropics as needed.

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Dementia due to other medical condition 294.1x

• Should use both Axis I and Axis III
• Axis I specifies that dementia exists whereas
  Axis III lists the underlying cause of the
  dementia.
• HIV
• Head Trauma
• Parkinsons
• Huntingtons
• Picks
• Creutzfelt-Jakob
• Etc

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Substance-induced persisting dementia

• Not just memory problems
• History of long-standing substance abuse
• Problems exist after discontinuation of substance
  abuse.
• ETOH 291.2
• All all other substances 292.82
• Morrison Vignette Mark Culpepper

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Dementia due to Multiple Etiologies

• Possible to have several causes of dementia
• E.g. head trauma Alzheimer's
• List both codes in Axis I.

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Amnestic Disorders

• Loss of short-term memory
• Most common cause is ETOH abuse Thiamine
  deficiency
• Recovery can occur, but chronicity is often the
  rule

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Amnestic Disorder due to a General Medical
Condition 294.0

• Likely to be due to
• Head trauma
• Hydrocephalus
• Encephalitis
• Hypoxia
• Stroke
• Etc.
• Diagnostic criteria
• Morrison p. 47, DSM-IV p. 177

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Substance-Induced Persisting Amnestic Disorder

• Korsakoffs syndrome (psychosis)
• Less common over the past few decades due to
  administration of thiamine during ETOH detox
• Effects of the substance last considerably longer
  than withdrawal.
• Diagnostic criteria
• Morrison p. 49-50 DSM-IV p. 179

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Amnestic Disorder NOS 294.8

• Used when theres insufficient information to
  make a more formal amnestic diagnosis.

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Cognitive Disorder NOS 294.9

• A cognitive disorder that doesnt meet any of the
  criteria listed (see p. 760-764 of the DSM-IV).
• Mild neurocognitive disorder that has impairment
  in cognitive function as evidenced by neuro
  testing.
• Postconcussion syndrome