Characteristics transient cognitive disorder core features: impairment of consciousness with attention deficit, rapid onset, fluctuating course. other phenomena may appear more prominent, but are not always present –psychomotor changes (agitation), perceptual changes as illusions and hallucinations, disorganized thought, delusions, disturbances of sleep, emotional changes (irritability, flatness of emotions)...
Historical notes middle ages: phrenitis, frenzy, febrile insanity 19th century: –„clouding of consciousness“ – lack of clarity of what it means –„confusion“ – lack of specificity to delirium „amency“/acute confusuinal state – terms describing milder states of delirium, obsolete 50s: attentional and other cognitive abnormalities are core features, associated with slowing on the EEG
Risk factors severity of physical illness older age baseline cognitive impairment (dementia)
Etiology manifestation of brain dysfunction due to systemic or brain disease or drug intoxication or withdrawal; often summation of causes –intoxication - anticholinergics, lithium, hypnotics, alcohol –withdrawal – hypnotics, alcohol –tumor –trauma, subdural hematoma –infection – cerebral, systemic –cardiovascular – cerebrovascular, cardial –metabolic – hypoxemia, electrolyte disturbances, renal or hepatic failure, hyper/hypoglycemia –endocrine – thyriod, glucocorticoid disturbances –nutritional – thiamin, B12 deficiency
Diagnosis Delirium due to general medical condition Substance intoxication delirium Substance withdrawal delirium Delirium due to multiple etiologies CRITERIA –Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain ro shift attention –A change in cognition (memory - recent, language, disorientation) or a perceptual disturbance not due to pre-existing dementia –rapid onset and fluctuating course
Treatment Treatment of primary medical condition minimizing doses of all sedative and psychoactive medications (except of alcohol or sedative withdrawal delirium) symptomatic control of agitation –high potency AP (haloperidol) –avoid low potency AP and sedative agents (benzodiazepines, antihistaminics) – worsening!!! –severe, life threatening agitation – sedation with controlled ventilation
Characteristics Definition: acquired impaired ability to learn and recall new information (and past events sometimes) No attention deficit or clouding of consciousness (delirium), no other cognitive dysfunction (dementia) Secondary syndromes caused by systemic medical or primary cerebral diseases, substance abuse disorders, medical adverse effects
Historical notes Korsakoff –alcoholic psychosis, ie severe disturbance of mental status DSM III, III-R – memory impairment (short, long-term memory) DSM IV –key feature = impaired learning –distinction vs. dementia: dementia = multiple impairment –transient vs. chronic forms (breakpoint = 1 month)
Etiology Diencephalic and middle temporal lobe structures (mammillary bodies, hippocampus) Causes of amnestic syndrome: –closed head trauma –penetrating missile wounds –focal tumors –surgical intervention –herpes simplex encephalitis –infarction of the territory of the posterior cerebral artery –hypoxia –chronic use of alcohol with thiamine deficiency Transient forms – linked with CVS disorders, pathology in the vertebrobasilar system, episodic physiologic or metabolic disorders, acute intoxications, seizures
Diagnosis Amnestic disorder due to a General Medical Condition Substance-induced persisting amnestic disorder CRITERIA –development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall previously learned information –significant impairment in social or occupational functioning due to the memory impairment –memory disturbance does not occur exclusively during the course of delirium or dementia
Differential diagnosis Delirium –memory impairment in the context of impaired consciousnes and reduced ability to sustain, focus ro shift attention –but – amnestic disorder may emerge from delirium (Korsakoff´s syndrome) Dementia –coexistence of memory impairment with multiple cognitive deficits Dissociative amnesia –lack of impaired learning new information – circumscribed inability to recall previously learned information with normal functioning in the present
Clinical notes Transient global amnesia –episodes of transitory inability to learn new information (to form memories) –variable inability to recall memories from the episode –restoration to completly intact cognitive state –no behavioral changes x may be confusion, perplexity sudden/gradual onset – according to the cause (head trauma, CNS event, chronic toxic exposure) disorientation – may be to place and time due to severe mnestic disorder x spared orientation to person (dementia) lack of insight confabulations
Treatment No effective treatments for amnestic disorder aimed specifically at learning deficit Treat underlying pathological process –rehabilitation after brain injury
References : Waldinger R.J.: Psychiatry for medical students, Washington, DC : American Psychiatric Press, 1997 Kaplan HI, Sadock BJ, Grebb JA.: Kaplan and Sadock´s synopsis of psychiatry, Baltimore: Williams and Wilkins, 1997
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