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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
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- 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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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