Cognitive Disorders Theme

YASER ALHUTHAIL, MDASSOCIATE PROFESSOR

PSYCHOSOMATIC MEDICINE

Abdullah is a 72-year-old male. He was brought to the A/E by his son for vomiting, new onset urinary incontinence, confusion, and incoherent speech for the past 2 days. The patient was disoriented and could see people climbing trees outside the window. He had difficulty sustaining attention, and his level of consciousness waxed and waned. He had been talking about his deceased wife. Patient was also trying to pull out his intravenous access line. Past history included diabetes mellitus, hyperlipidemia, osteoarthritis, and stroke. The patient's family physician had recently prescribed Tylenol with codeine for the patient's severe knee pain 5 days earlier.

On examination : drowsy, not cooperative with the physical examination.

Abdomen :flat and soft with normal bowel sounds. The patient moves all 4 limbs and plantar is bilateral flexor.

Laboratory tests : elevated BUN and creatinine levels, and the urine analysis was positive for UTI.

CT scan of the head showed cortical atrophy plus an old infarct.

Psychopathology

ConsciousnessOrientationAttentionConcentrationMemory

Disruption in one or more of the cognitive domains, and are also frequently complicated by behavioral symptoms.

Cognitive disorders exemplify the complex interface between neurology, medicine, and psychiatry

Delirium, dementia, and the amnestic disorders

DeliriumAcute onset of fluctuating cognitive impairment (global)and a disturbance of consciousness.

Delirium is a syndrome, not a disease, and it has many causes, all of which result in a similar pattern of signs and symptoms

A common disorder:

10 to 30 percent of medically ill inpatients

30 percent of patients in intensive care units and

40 to 50 percent of patients who are recovering from surgery for hip fractures

Underrecognized and undertreated !!

Classically, delirium has a sudden onset (hours or days)

A brief and fluctuating course

Rapid improvement when the causative factor is identified and eliminated

Abnormalities of mood, perception, and behavior are common psychiatric symptoms

Tremor, asterixis, nystagmus, incoordination, and urinary incontinence are common

Risk FactorsExtremes of age

Number of medications taken

Preexisting brain damage (e.g., dementia, cerebrovascular disease, tumor)

History of delirium

Alcohol dependence

Diabetes

Cancer

Sensory impairment

Malnutrition

Central nervous system disorder

Seizure (postictal, nonconvulsive status, status)MigraineHead trauma, brain tumor, subarachnoid hemorrhage, subdural, epidural hematoma, abscess, intracerebral hemorrhage, cerebellar hemorrhage, nonhemorrhagic stroke, transient ischemia

Metabolic disorder Electrolyte abnormalitiesDiabetes, hypoglycemia, hyperglycemia, or insulin resistance

Systemic illness Infection (e.g., sepsis, malaria, erysipelas, viral, plague, Lyme disease, syphilis, or abscess)TraumaChange in fluid status (dehydration or volume overload)Nutritional deficiencyBurnsUncontrolled pain

Medications Pain medications Antibiotics, antivirals, and antifungalsSteroidsAnesthesiaCardiac medicationsAntihypertensivesAntineoplastic agentsAnticholinergic agents

Cardiac Cardiac failure, arrhythmia, myocardial infarction, cardiac assist device, cardiac surgery

Pulmonary Chronic obstructive pulmonary disease, hypoxia, SIADH, acid base disturbance

Endocrine Adrenal crisis or adrenal failure, thyroid abnormality, parathyroid abnormality

Hematological Anemia, leukemia, blood dyscrasia, stem cell transplant

Renal Renal failure, uremia, SIADHHepatic Hepatitis, cirrhosis, hepatic failure

Neoplasm Neoplasm (primary brain, metastases, paraneoplastic syndrome)

Drugs of abuse

Intoxication and withdrawal

Toxins Intoxication and withdrawalHeavy metals and aluminum

Diagnostic Criteria for Delirium Due to General Medical Condition

A-Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.

B-A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.

C-The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

D-There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

Diagnosis and Clinical FeaturesThe core features of delirium include:

Altered consciousness

Altered attention, which can include diminished ability to focus, sustain, or shift attention

Impairment in other cognitive functions, which can manifest as disorientation and decreased memory

Fluctuations in severity and other clinical manifestations during the course of the day, sometimes worse at night (sundowning)

Disorganization of thought processes

Perceptual disturbances

Psychomotor hyperactivity and hypoactivity

The major neurotransmitter hypothesized to be involved in delirium is acetylcholine

Anticholinergic activity

Laboratory Workup of the Patient with Delirium

Blood chemistries (including electrolytes, renal and hepatic indexes, and glucose)   Complete blood count with white cell differential   Thyroid function tests   Serologic tests for syphilis   Human immunodeficiency virus (HIV) antibody test   Urinalysis   Electrocardiogram   Electroencephalogram   Chest radiograph   Blood and urine drug screens

Differential Diagnosis

Dementia

Depression

Schizophrenia

Course and Prognosis

The symptoms of delirium usually persist as long as the causally relevant factors are present

Delirium is a poor prognostic sign

Treatment

The primary goal is to treat the underlying cause

The other important goal of treatment is to provide physical, sensory, and environmental support

Pharmacotherapy

haloperidol

risperidone, clozapine, olanzapine, quetiapine

Past history inquiry indicated that he has two years of deteriorating memory. He forgets mostly recent things and has difficulty to name some familiar people.

6 months ago, he lost his ability to drive and to pray appropriately. However, his attention was well except of few days’ prior current admission.

There is positive family history of sever memory problem in his eldest brother.

DementiaGlobal impairment of cognitive functions occurring in clear

consciousness

Difficulty with memory, attention, thinking, and comprehension.

Other mental functions can often be affected, including mood, personality, judgment, and social behavior

Can be progressive or static !

Permanent or reversible (e.g., vitamin B12, folate, hypothyroidism)   

50 to 60 percent have the most common type of dementia, dementia of the Alzheimer's type

Vascular dementias account for 15 to 30 percent of all dementia cases

Possible Etiologies of Dementia Degenerative dementias

Alzheimer's disease Frontotemporal dementias (e.g., Pick's disease) Parkinson's disease Lewy body dementia Miscellaneous Huntington's disease Wilson's disease Psychiatric Pseudodementia of depression Cognitive decline in late-life schizophrenia Physiologic Normal pressure hydrocephalus Metabolic Vitamin deficiencies (e.g., vitamin B12, folate) Endocrinopathies (e.g., hypothyroidism) Chronic metabolic disturbances (e.g., uremia) Tumor Primary or metastatic (e.g., meningioma or metastatic breast or lung cancer)

Traumatic Dementia pugilistica, posttraumatic dementia Subdural hematomaInfection Prion diseases (e.g., Creutzfeldt-Jakob disease, bovine spongiform encephalitis, Gerstmann-Strأ¤ussler syndrome) Acquired immune deficiency syndrome (AIDS) SyphilisCardiac, vascular, and anoxia Infarction (single or multiple or strategic lacunar) Binswanger's disease (subcortical arteriosclerotic encephalopathy) Hemodynamic insufficiency (e.g., hypoperfusion or hypoxia)Demyelinating diseases Multiple sclerosisDrugs and toxins Alcohol, Heavy metals, Carbon monoxide

Dementia of the Alzheimer's Type

The most common type of dementia

Progressive dementia

The final diagnosis of Alzheimer's disease requires a neuropathological examination of the brain

Genetic factors

Acetylcholine and norepinephrine, both of which are hypothesized to be hypoactive in Alzheimer's disease

Vascular Dementia

The primary cause of vascular dementia, formerly referred to as multi-infarct dementia, is presumed to be multiple areas of cerebral vascular disease

Vascular dementia is more likely to show a decremental, stepwise deterioration than is Alzheimer's disease.

Diagnosis and Clinical Features

The diagnosis of dementia is based on the clinical examination

Memory impairment is typically an early and prominent feature

Early in the course of dementia, memory impairment is mild and usually most marked for recent events; As the course of dementia progresses, memory impairment becomes severe, and only the earliest learned information are intact

Orientation can be progressively affected

Personality change, intellectual impairment, forgetfulness, social withdrawal, anger and lability of emotions are common

Hallucinations………….20 to 30 percent

Delusions………………30 to 40 percent

Physical aggression and other forms of violence are common in demented patients who also have psychotic symptoms.

Depression and anxiety symptoms

Pathological laughter or crying

Diagnostic Criteria for Dementia of the Alzheimer's TypeA-The development of multiple cognitive deficits manifested by both

1-memory impairment (impaired ability to learn new information or to recall previously learned information)

2-one (or more) of the following cognitive disturbances: aphasia (language disturbance)

apraxia (impaired ability to carry out motor activities despite intact motor function)

agnosia (failure to recognize or identify objects despite intact sensory function)

disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B-The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

C-The course is characterized by gradual onset and continuing cognitive decline. D-The cognitive deficits in Criteria A1 and A2 are not due to any of the following:

1-other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)

2-systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)

3-substance-induced conditions

E-The deficits do not occur exclusively during the course of a delirium. F-The disturbance is not better accounted for by another Axis I disorder (e.g., major

depressive disorder, schizophrenia

Diagnostic Criteria for Vascular Dementia A.The development of multiple cognitive deficits manifested by both

A. memory impairment (impaired ability to learn new information or to recall previously learned information)

B. one (or more) of the following cognitive disturbances: A. aphasia (language disturbance) B. apraxia (impaired ability to carry out motor activities despite intact motor

function) C. agnosia (failure to recognize or identify objects despite intact sensory

function) D. disturbance in executive functioning (i.e., planning, organizing, sequencing,

abstracting)B.The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. C.Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance. D.The deficits do not occur exclusively during the course of a delirium.

Dementia Due to Other General Medical Conditions

HIV disease, head trauma, Parkinson's disease, Huntington's disease, Pick's disease, and Creutzfeldt-Jakob disease.

Substance-Induced Persisting Dementia

Alcohol-Induced Persisting Dementia

Physical Findings, and Laboratory Examination

A comprehensive laboratory workup must be performed when evaluating a patient with dementia

The purposes of the workup are to detect reversible causes of dementia

The evaluation should follow informed clinical suspicion

Differential Diagnosis

Delirium

Depression (pseudodementia )

Schizophrenia

Normal Aging

Feature Dementia DeliriumOnset Slow Rapid

Duration Months to years Hours to weeks

Attention Preserved Fluctuates

Memory Impaired remote memory Impaired recent and immediate memory

Speech Word-finding difficulty Incoherent (slow or rapid)Sleep cycle Fragmented sleep Frequent disruption (e.g.,

day–night reversal)

Thoughts Impoverished Disorganized

Awareness Unchanged Reduced

Alertness Usually normal Hypervigilant or reduced vigilance

TreatmentThe first step in the treatment of dementia is verification of

the diagnosis.

Preventive measures are important

Supportive and educational psychotherapy

Any areas of intact functioning should be maximized by helping patients identify activities in which successful functioning is possible

Caregivers

Pharmacotherapy

Benzodiazepines for insomnia and anxiety

Aantidepressants for depression

Antipsychotic drugs for delusions and hallucinations

Drugs with high anticholinergic activity should be avoided.

Cholinesterase inhibitors :

Donepezil (Aricept), rivastigmine (Exelon), galantamine (Remiryl), and tacrine

Abdullah’s son reluctantly reported that his father has current history of occasional alcohol drinking .

He admits that he was a heavy alcohol drinker 10 years ago. He had bouts of memory impairments and family problem secondary to his heavy drinking. He used to have tremors and craving for drinking at early morning. After searching patient’s old medical notes, you found that the patient has been admitted to ICU 10 year ago with fever, sweating, tremor, dilated eyes, disorientation, confusion and seeing small animals.

Moreover, the patient’s medical notes indicates that he came to ER 25 years ago complaining of runny nose, stomach cramps, dilated pupils, muscle spasms, chills despite the warm weather, elevated heart rate and blood pressure, and low grade fever. At that time, he has asked ER physician some “meds” to tide him over until he can see his regular doctor.

Abuse: Self-administration of any substance in a culturally disapproved manner that causes adverse consequences.

Dependence: The physiological state of neuroadaptation produced by repeated administration of a drug, necessitating continued administration to prevent the appearance of the withdrawal state.

Addiction: A nonscientific term that implies dependence.

Intoxication: The transient effects (physical and psychological) due to recent substance ingestion, which disappear when the substance is eliminated.

Withdrawal: A group of symptoms and signs occurring when a drug is withdrawn or reduced in amount.

Tolerance: The state in which the same amount of a drug produces a decreased effect, so that increasingly larger doses must be administered to obtain the effects observed with the original use.

Risk factors of Alcohol abuse

Vulnerable personality: impulsive, less conforming, isolated or avoidant persons.

Vulnerable occupation: senior businessmen, journalists, doctors.

Psychosocial stresses: social isolation, financial, occupational or academic difficulties, and marital conflicts.

Psychiatric problems: anxiety, chronic insomnia depression.

Alcohol WithdrawalStages

• I (24 – 48 hours):

• II (48 – 72 hours):

• III (72 – 105 hours):

• IV (> 7 days):

Symptoms

Peak severity at 36 hours

Most cases self-limited

Stage I symptoms

“Delirium Tremens”

Protracted withdrawal

Alcohol withdrawal85% mild-to-moderate15% severe and complicated:

Seizures Delirium Tremens

Features :Tremulousness (hands, legs and trunk).Nausea, retching and vomiting.Sweating, tachycardia and fever.Anxiety, insomnia and irritability.Cognitive dysfunctions.Thinking and perceptual disturbances.

Delirium Tremens (DTs)Features:Delirium.

Gross tremor .

Autonomic disturbances .

Dehydration and electrolyte disturbances..

Marked insomnia.

Course :Peaks on third or fourth day, lasts for 3 – 5 days

Complications :

Seizures.

Chest infection, aspiration.

Violent behaviour.

Coma.

Death; mortality rate: 20%. >>>>>>>> Medical emergency

Treatment

The best treatment is prevention

Supportive

Thiamine

Long acting BDZ (chlordiazepoxide 25-50 mg every 2-4hrs )………(50-100 mg every 4 hrs)

Avoid antipsychotics. 

Complications of chronic ETOH abuse

Medical psychiatric Social

NeurologicalCerebellar degenerationSeizuresPeriphral neuropathyOptic nerve atrophyhead trauma

AlimentaryTumours (oesophagus, liver..)gastritis, peptic ulcerPancreatitishepatitis, cirrhosis

Others:cardiomyopathyanaemiaobesityimpotencegynaecomastia

amnesic disorderdeliriumdementiapsychosisdepressionreduced sexual desireinsomniapersonality deteriorationsuicidemorbid jealousy

social isolationjob lossmarital conflictsfamily problemslegal troublessocial stigmaothers

OPIOIDS

Heroin, morphine, codeine, pethidine, methadone.

They are abused for their powerful euphoriant effects.

Tolerance develops rapidly & diminishes rapidly!!

Withdrawal symptoms:  6 hours after the last dose, reach a peak after 36 - 48 hours, and then wane.

Severe craving, very distressful but have no serious medical consequences

Lacrimation, muscle and joint pain, cold and hot flushes, nausea, vomiting and diarrhoea, and piloerection

Opioids ( clinical effects)

Psychological Physical

euphoriarelaxation

drowsinessanalgesiareduced sexual desire

small pupilbradycardiareduced appetiteconstipationrespiratory depressionI.V use:

*AIDS * hepatitis

*endocarditis * septicemia

*Acute local infections

Treatment:*Opioid overdose : supportive +naloxone*Opioid Withdrawal: symptomatic treatment, Counseling, individual or group therapy* Harm reduction strategies: methadone

Valid Informed Consent

Permission given by a competent person without any elements of force, deceit, coercion after explanation and disclosure of:

Purpose and details of procedure or treatment

Risks, Benefits and available alternative treatment/s

The right to withdrawal consent verbally or in written forms at anytime

Exceptions!!!

Being mentally ill doesn’t in itself imply a loss of capacity or competency.

Having Capacity or being Competent until proven otherwise.

To have capacity to consent to “treatment”, 4 criteria must be satisfied in a patient:

To understand relevant information about the PROPOSED treatment/ treatment OPTIONS/ NO treatment

Able to communicate a choice consistently

To appreciate own clinical situation (insight) with regard to the proposed treatment (if a patient is in denial of illness, s/he will not be considered competent)

To rationally manipulate (reasonable; sensible; sound judgment) provided information/s