geropsychiatry: delirium and dementia

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1. Geropsychiatry: Delirium and Dementia Robert Averbuch, MD Assistant Professor Department of Psychiatry

2. Disorders of Cognition DSM-IV devotes an entire section to a subset of “organic” disorders that primarily affect cognition: “Delirium, Dementia, and Amnestic and other Cognitive Disorders”

3. What is “organic”? Previous differentiation between mental disorders with a clear “physical or biological” etiology (Organic) and those without (“Functional” or “Primary”) Falsely implied that Functional (or primary) disorders have no underlying pathophysiological basis Primary mental disorder- not due to a GMC or substance

4. Disorders of Cognition Delirium-disturbance in consciousness and cognition that develops rapidly Dementia- multiple cognitive deficits that include memory disturbance Amnestic Disorder- primarily memory impairment

5. Delirium

6. Delirium: defined Disturbance of consciousness (awareness of the environment) and attention, PLUS… Changes in cognition (ie, “thinking”-memory, orientation, language, etc) OR Perceptual disturbances

7. The Course of Delirium Evolves rapidly (hrs to days) Usually resolves rapidly as well: May be self-limited, persist for weeks, or progress to death Degree of impairment fluctuates

8. Delirium: Associated Features Disturbance in sleep-wake cycle Easily distracted by irrelevant stimuli Changes in activity level Restlessness, hyperactivity Picking at clothes, getting out of bed OR hypoactivity (lethargy) Emotional disturbances- mood lability, anger, irritability, euphoria, apathy

9. Delirium: Associated Features Speech or language disturbances Perceptual abnormalities- common: Illusions, hallucinations, delusions Neurological deficits/dysfunction

10. What Are the Causes? DIRECT: Brain pathology: head injury, seizures (during and after), strokes, infections INDIRECT: Systemic Illness: electrolyte abnormalities, dehydration, uremia, hepatic encephalopathy, cardiovascular compromise

11. More Causes of Delirium Sensory deprivation After surgery (post-operative state)- ie. “ICU Psychosis” Side effects of medications or toxins or with abused recreational drugs: “Substance-Induced Delirium” Ex. NMS (Neuroleptic Malignant Syndrome) Ex. Serotonin Syndrome

12. Treating Delirium Considered a Medical Emergency Supportive care in an ICU setting Safety- close monitoring Remove offending agent, treat underlying cause

13. Dementia

14. Hallmark is Memory Impairment Memory problems usually evident early Memory impairment alone is not enough to make the diagnosis…

15. Dementia- defined Memory problems AND at least one additional cognitive deficit: Aphasia Apraxia Agnosia Problems with “executive functioning”

16. Details, Details: Aphasia Aphasia is a drop off in language function that shows up in a variety of ways

17. Apraxia “impaired ability to pantomime the use of known objects or to execute known motor acts”

18. Agnosia Trouble recognizing or identifying things despite intact sensations (ex. You can see fine, but you can’t recognize a stop sign) May include difficulty recognizing family members or even themselves in the mirror

19. Disturbances in Executive Functioning Abstract thinking Planning, initiating, sequencing, and stopping behaviors May manifest as trouble with novel tasks or new situations

20. Associated Features Spatial disorientation Poor insight and judgment means…they get themselves in trouble by overestimating their abilities and underestimating risks Perceptual Abnormalities: Delusions- especially persecution Hallucinations- especially visual

21. More associated features Personality Changes: Disinhibition Neglect of personal hygiene Apathy and withdrawal

22. Course of Dementia Course may be progressive, static, or remitting Small percentage of cases are reversible

23. What causes Dementia? Alzheimer’s is by far the most common type Cerebrovascular Disease Degenerative Diseases: Parkinson’s, Huntington’s, CJD (Mad Cow Disease)

24. More causes: Autoimmune Illness Lupus Multiple Sclerosis B12, Folate Deficiencies Head Trauma, Brain Tumors Infections- like HIV and Syphilis

25. Alzheimer’s

26. Dementia of the Alzheimer’s Type (DAT) Diagnosis of exclusion Hallmark: gradual onset of recent memory problems Onset may be early (65 y/o or younger) or Late (over 65)

27. DAT Slowly progressive (8-10 years from diagnosis to death) Many show personality changes Often with associated behavioral disturbances (wandering, agitation, etc.)

28. Vascular Dementia Aka Multi-Infarct Dementia

29. Vascular Dementia Evidence of cerebrovascular disease on physical exam and head scans Usually caused by several strokes over time Onset abrupt, followed by stepwise, fluctuating course with “patchy” deficits

30. Treatment of Dementia Search for a reversible cause and treat (ex. B12 deficiency, Normal Pressure Hydrocephalus, Syphilis, etc) Rule out Pseudodementia (change in cognition associated with depression) Environmental/behavioral interventions- ex. no fail environment Medications

31. Medications Cholinesterase Inhibitors: Aricept (donepezil) Reminyl (galantamine) Exelon (rivastigmine)

32. Medications NMDA-receptor antagonists Namenda (memantine) Neuroprotective by blocking excessive glutamate stimulation of the NMDA (N-methyl-D-aspartate) receptor

33. The End

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