Cognitive Disorders Handout

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Delirium, Dementia & Amnestic Disorder Delirium - What is delirium? o A clinical syndrome (or set of symptoms) of disturbances in consciousness that is accompanied by symptomatic manifestations of early brain dysfunction, which can not be better explained by dementia - What are the main symptoms? o Confusion  Aphasia – impairment in understanding & producing speech  Dysarthia – impaired articulation o Disorientation o Cognitive changes  Constructional apraxia - difficulty drawing  Dysnomia – impaired ability to name objects - What are the different types of diagnostic deliriums o Delirium due to a medical condition o Delirium due to substance intoxication o Delirium due to substance withdrawal o Delirium due to multiple etiologies o Delirium not otherwise specified - What are other possible effects? o Emotional disturbances (e.g. fear, anxiety, euphoria, depression, anger, apathy) o Tremors o Autonomic hyperactivity (e.g. while seating, raised HR & BP) o Reversal of night-day sleep-wake cycle o Extreme shifts in psycho-motor activity - Who is at risk? o Elderly (>60) o Children o Those in substance withdrawal or preexisting brain injuries - What is the course? o Begins abruptly o Usually resolves within days o Resolution depends on swift identification & correction of etiological factors o Complete recovery is common - Differential Diagnosis o Dementia (most common problem) o Substance intoxication/withdrawal o Brief psychotic disorder o Mood disorder with psychotic features o Schizophrenia o Schizophreniform Disorder – typical cause if subject is young o Acute Stress Disorder o Malingering & Factitious Disorder - Are there other causes? o Severe medical or mental illness

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o Fever o Poisoning o Brain injury o Severe lack of food or water o Sleep deprivation o Excess stress Key Diagnostic Point o Distinguishing feature is a disturbance of consciousness accompanied by some changes in cognition

Dementia - What is dementia? o A gradual deterioration of brain functioning that affects judgment, memory, language & other advanced cognitive processes Play video - What are the main symptoms o The individual & cause may have impact on which initial symptoms show, but eventually all aspects of cognitive function become affected. o No disorientation or confusion like delirium o Memory impairment is typically seen as an inability to register ongoing events o One or more of the following cognitive disturbances:  Agnosia - the inability to recognize objects despite intact sensory function  Aphasia - a disturbance in language that differs depending on the area of the brain affected.  Apraxia - the inability to carry out motor activities that the individual was previously able to perform  Impairment in executive functioning – (i.e. planning, organizing, abstraction) o Advanced dementia patients can not feed, bath or dress themselves - What are the types of dementia? Characteristic Cortical (Alzheimer’s) Subcortical Dementias Language Aphasia No aphasia Memory Recall & recognition Impaired recall; normal or impaired less impaired recognition Visuospatial Skills Impaired Impaired Mood Less severe depression & More severe depression & anxiety anxiety Motor speed Normal Slowed Coordination Normal until late in Impaired progression o Dementia of the Alzheimer’s type o Vascular dementia o Dementia due to other general medical conditions  Diseases • HIV (human immunodeficiency virus) • Head trauma • Parkinson’s Disease • Huntington’s Disease

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• Pick’s Disease • Creutzfeldt-Jakob Disease o Substance-induced persisting dementia o Dementia due to multiple etiologies o Dementia not otherwise specified What are other possible side effects o Emotional changes Who is at risk? o Highest incidence in older adults o Incident rates for ages  (75-79  2.3%, 80-84  4.6%, 85 & older  8.5%) What is the course? o Cognitive functioning continues to deteriorate until the patient requires almost total support to carry on day-to-day o Death occurs from inactivity combined with an illness such as pneumonia Differential Diagnosis o Delirium o Schizophrenia (multiple cog. Impairments & decline in functioning) o MDD (Major Depressive Disorder) o Age Related Cognitive Decline What are the causes of dementia o Brain trauma o Infectious diseases o Toxic or poisonous substances o Diseases o Genetics  Deterministic genes  Susceptibility genes What is the treatment? o Unlike most disorders where treatment prospects are fairly good – this is unfortunately not the case with dementia o There is no way to replace neurons & plasticity can only go so far o Goals of treatment shift from cure to:  Try to prevent controllable conditions that bring on dementia  Try to stop brain damage from spreading & getting worse  Attempt to help patients cope with advancing deterioration  Efforts are being made to help caregivers- the unintended other victims of dementia o Biological Treatments o Psychosocial Treatments Prevention o Estrogen replacement therapy decreases the risk of dementia of the Alzheimer’s type in women o Proper treatment of systolic hypertension o Non-steroidal anti-inflammatory drugs Key Diagnostic Point o Distinguishing feature is a memory impairment accompanied by at least one major cognitive disturbance (i.e. aphasia, apraxia, agnosia)

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4 Amnestic Disorder - What is amnestic disorder o The loss of memory without the loss of other high-level cognitive functions  the inability to transfer information into long-term memory, which can cover minutes, hours or years - What are the main symptoms o Inability to learn new information or to recall previously learned information - What is the course? o Variable o Acute onset o Subtle onset o Due to head trauma is largely variable - What are the types of amnestic disorder o Based on etiology o Amnestic disorder due to a general medical condition (i.e. physical trauma or vitamin deficiency) o Substance-induced persisting amnestic disorder (includes medication side effects)  Alcohol-induced persisting amnestic disorder from prolonged, heavy ingestion of alcohol & the resulting thiamine deficiency is known as Korsakoff’s Syndrome  Sedative-, Hypnotic-, or Anxiolytic-Induced Disorder o Amnestic Disorder Not Otherwise specified - Differential Diagnosis o The ability to immediately repeat a sequential string of information - failure shows problems with attention  delirium o Memory impairment with any cognitive impairment  dementia - Key Diagnostic Point o Distinguishing feature is memory impairment without other cognitive deficits Making A Diagnosis - 1st – the initial recognition that the patients symptoms are consistent with one of the recognized syndromes of cognitive impairment - 2nd – the search for an underlying physiological cause for the behavior - Does the patient have disturbances of consciousness? o No  delirium ruled out - Does the patient have an impairment of cognition? o Can appear in many areas - memory, orientation, perception, language ability, motor activity, object recognition, abstract reasoning o If patient’s only impairment is in memory disturbances  amnestic disorder o If patient has disturbances in consciousness & impairment in cognition that tends to fluctuate over the course of the day  delirium o If patient has memory disturbance & a cognitive impairment w/o disturbance in consciousness dementia - What is the temporal basis of the patient’s disturbance o Delirium & dementia can sometimes be differentiated by the time course of the appearance of symptoms & their change over time o Cognitive impairments develop slowly (weeks & months) & remain stable w/ little fluctuation over the course of the day  dementia o Cognitive impairments develop rapidly (hours & days), worsen rapidly & fluctuate  delirium