DELIRIUM, DEMENTIA, AND AMNESTIC CONDITIONS

DELIRIUM

• Marked by short-term confusion and changes in cognition

• A.K.A. acute confusional state, acute brain syndrome, metabolic encephalopathy, toxic psychosis, & acute brain failure

• syndrome, not a dse

• characterized by a disturbance of consciousness & a change in cognition that develop over a short time.

• Hallmark symptom : impairment of consciousness

Delirium - Clinical Manifestations

• Tremor

• Fluctuating levels of consciousness

• Clouding of consciousness

• Disorientation

• Illusions

• Hallucinations

• Dysphasia

• Dysarthria

Delirium - Causes

1. Gen. Medical Condition-e.g. infection

2. Substance Induced- e.g. cocaine

3. Multiple Causes- e.g. head trauma, kidney dse.

4. not otherwise specified-e.g. sleep deprivation

DEMENTIA

• marked by severe impairment in memory, judgement, orientation & cognition.

Subcategories of Dementia

• Dementia of Alzheimer’s Type

  • manifested by progressive intellectual disorientation, dementia, delusions, or depressions.

• Vascular Dementia

  • vessel thrombus hemorrhage

• Other Medical Conditions

  • HIV dse, trauma

• Substance Induced - Toxin/Meds

• Multiple Etiologies and Others not Specified

AMNESTIC DISORDER

• Marked by memory impairment and forgetfulness

AMNESTIC DISORDER - CAUSES

• by medical condition (hypoxia)

• by toxin/meds- marijuana

• others not specified (trauma)

DIFFERENTIAL DIAGNOSIS

Onset:

• Delirium - sudden onset

• Dementia – insidious (slowly) 

  • with dementia- usually alert

  • with delirium- has episodes of dec. consciousness

• Beclouded dementia- delirium occurs to pt. with dementia

TREATMENT

• Primary Goal: Treat the underlying cause

• Provide physical, sensory, environmental support

• Pharmacotherapy

  • 2 major symptoms: psychosis & insomnia

    • e.g. haloperidol- antipsychotic drug

• Benzodiazepine- insomnia

DEMENTIA

• a diminution in cognition in the setting of a stable level of consciousness.

• "characterized by multiple cognitive defects that include impairment in memory" (DSM-IV-TR)

• may be progressive or static, permanent or reversible

• Memory impairment- prominent feature in dementia

DEMENTIA OF THE ALZHEIMER’S TYPE

• Genetic Factors - 40%

• Neuropathology - diffuse atrophy with flattened cortical sulci and enlarged cerebral ventricles.

• Neurotransmitters - acetylcholine & norepinephrine

• Other Causes

  • carried on chromosome 17

  • short term memory problems; difficulty maintaining balance & walking

  • protein build up kills brain cells

VASCULAR DEMENTIA

• affects small & medium cerebral vessels

• Most common - men with Htn, cardiovascular problem

BINWANGER’S DISEASE

• a.k.a. subcortical arteriosclerotic encephalopathy (clotting)

• presence of many small infections of the white matter that spare the cortical region.

PICK’S DISEASE

• atrophy in the frontotemporal regions

• 5% of all irreversible dementia

•  early stage: characterized by personality & behavioral changes, with preservation of other cognitive functions.

• e.g. Kluver-bucy syndrome-more common in pick's

LEWY BODY DISEASE

• often characterized by hallucinations, parkinsonian features, and extrapyramidal signs.

HUNTINGTON’S DISEASE

• associated with the dev't of dementia

• characterized by more motor abnormalities and fewer language abnormalities

PARKINSON'S DISEASE

• 20-30 % of patients

• bradyphrenia-slow thinking and movement

• Unintended or uncontrollable movements, such as shaking, stiffness and difficulty with balance and coordination. 

HIV-Related Dementia

• 14% annually

• other infectious dementia are caused by cryptococcus & treponema pallidum

Head Trauma -Related Dementia

• punch-drunk syndrome (dementia pugilistica) - occurs in boxers

• Chronic traumatic encephalopathy

• characterized by emotional lability, dysarthria, & impulsivity.

DIFFERENTIAL DIAGNOSIS - DEMENTIA

• symptoms of psychosis & thought d/o: schizophrenia>dementia

• Normal Aging- minor memory deficit- benign senescent forgetfulness

• Other disorders

  • MR- no memory impairment

  • Amnestic d/o- characterized by circumscribed loss of memory and no deterioration

COURSE & PROGNOSIS - DEMENTIA

• Onset- 50s-60s with gradual deterioration over 5-10 yrs

• Survival expectation

  • Alzheimer's type: ≈8 yrs

TREATMENT - DEMENTIA

• verification of the diagnosis

• Preventive measures

• Provide supportive medical care, emotional support, pharmacological treatment for specific symptoms

AMNESTIC DISORDER

• feature is the acquired impaired ability to learn & recall new information, or inability to recall previously learned knowledge or past events

AMNESTIC DISORDER - ETIOLOGY

• diencephalic structures involvement & usually bilateral damage 

• systemic medical condition (Korsakoff's syndrome); hypoglycemia; primary brain conditions (seizures, head trauma); substance-related causes (alcohol use d/o)

AMNESTIC DISORDER - CLINICAL FEATURES

• central symptom- dev't of memory d/o

• short term/recent memory are usually impaired

• sudden onset of symptoms

• can be short or long duration

SUBTYPES - AMNESTIC DISORDER

1. CVD

2. MS

3. KORSAKOFF’S SYNDROME

4. ALCOHOLIC BLACKOUTS

5. ELETROCONVOLSIVE THERAPY

6. HEAD INJURY

7. TRANSIENT GLOBAL AMNESIA

CVD

• often involve the occipital or parietal lobes

• affecting bilateral medial thalamus (ant. portions) assoc. with sx. of amnestic d/o

MS

• plaques occur in temporal lobe & diencephalic regions

• memory impairment- 46-60 %

KORSAKOFF’S SYNDROME

• Korsakoff syndrome is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). Korsakoff syndrome is most commonly caused by alcohol misuse

• Develops in about 80% of people with untreated Wernicke encephalopathy

• often assoc. with Wernicke's encephalopathy-confusion, ataxia, and ophthalmoplegia (paralysis or weakness of the eye muscles)

  • Acute confusional state

  • onset may be gradual

  • Prominent symptoms- confabulation, apathy, & passivity

ALCOHOLIC BLACKOUTS

• person's awake in the morning with a conscious awareness of being unable to remember a period the night before which they were intoxicated

ELECTROCONVOLSIVE THERAPY

• usually assoc. with retrograde amnesia for a period of several minutes and anterograde amnesia after the treatment (within 5 hours).

• 1-2 months mild memory deficits after the course of Tx, but sx completely resolved 6-9 months

 HEAD INJURY

• retrograde amnesia - improvement during the 1st week of gain consciousness

TRANSIENT GLOBAL AMNESIA

DIFFERENTIAL DIAGNOSIS

• Dementia- memory impairment with other cognitive deficits

• Delirium- memory impairment occurs in the setting of impaired attention and consciousness

• Normal aging- minor impairment in memory

• Dissociative d/o- lost orientation to self and may have more selective memory deficits

  • experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity.

• Factitious d/o - mimicking an amnestic d/o

  • is a serious mental disorder in which someone deceives others by appearing sick, by purposely getting sick or by self-injury.

  • inconsistent results on memory test & no evidence of an identifiable cause