Cognitive Disorders Delirium Dementia Amnestic Disoders

Characteristics These disorders are not developmental Delirium and dementia often appear together One may be imposed upon the other Symptoms are consistent with one of the recognized syndromes of cognitive impairment Search for an underlying physiological cause for the symptoms Assess using a team-based approach

Diagnostic Process Symptoms consistent with recognized cognitive impairment Search for underlying physiological cause Team based assessment

Recording Procedures Axis I – presence of cognitive problem due to general medical condition Axis III – underlying medical problem with ICD number Provisional diagnosis – if unclear what cognitive deficits due to With dementia: Note if there is a behavioral disturbance

Superimposed If in progression of existing dementia –delirium develops subtype is noted An example –Dementia, Alzheimer’s type, late onset, with Delirium Dementia diagnosed 1 st, the delirium arrived

Differences Delirium –Disturbance in consciousness accompanied by widespread brain dysfunction Dementia –Distinguished by impairment in memory sort or long term recent & remote –Also impairment of 1 other brain function Both: Exhibit signs & symbols of global brain dysfunction

Dementia Can be referred to as senility, gradual deterioration of intellectual abilities to where it impairs social and occupational functioning Multiple cognitive deficits which are skill oriented, indicate global brain dysfunction Easier to diagnose than delirium Clients may present with cognitive disturbances

Dementia May be caused by: –nonpsychiatric medical condition –a substance or –mixture Terms –Aphasia – inability to understand or produce language –Apraxia – loss of motor skill –Agnosia – problems with visual & spatial

Causes of Dementia Over 70 possible causes Alzheimer's –diagnosed only by ruling other things out Primary dementias –produced directly by brain impairment Secondary dementias –caused by diseases not attacking brain directly Depression Hormonal imbalances Drugs Arteriosclerosis Pneumonia HIV etc

What Does Dementia Look Like? Early progression –Client may be aware of deficits Numerous Attempts to hide –Rigid patterns for daily life –Avoid departure from routine Denial –including family No typical case –Signs/symptoms vary greatly –Depends on cause, course, severity of underlying disease or problem –Region of brain affected looks different –Personality before dementia MSE focus –Memory loss –Difficulty with problem solving –Language –Vision-spatial coordination –Numbers

Differential Diagnosis - Dementia Consider: –Normal aging –Delirium –Schizophrenia –Major depressive disorder (depressive pseudodementia) –Factitious disorder with psychological symptoms Females are most misdiagnosed Important to look at dementia vs. depression

Dementia versus Depression Both may have poor judgment, somatic complaints, & psychotic behaviors In Dementia –Memory deficits –Perseveration –Affect is “suggestible” –Affect is inconsistent In Depression –Difficulty in concentration –Difficulty learning new information –Affect is not influenced by others –No cognitive disturbances

Dementia: Treatment Possibilities Depends on type of dementia diagnosed No treatment for biological component Find cause and attempt to treat it first Focus on client management and environment Some types of medication may help Counseling for client and support group

Delirium Disturbance of consciousness & change in cognition Decline from higher functioning Impairment in occupational or social functioning Difficulties with assessment –Need medical tests –Accurate MSE –Accurate history –Primary cause may no longer be present –Children more susceptible to delirium from meds Often misdiagnosed

Causes of Delirium General medical –Fever –Hypoxia (lack of oxygen) –Ischemi (lack of blood flow to brain) –brain infections such as meningitis Persisting effects of substance –Many medications & drugs can cause delirium during or after use Seizure or traumatic brain injury Multiple etiologies

What does delirium look like? Cannot concentrate –Difficulty maintaining or shifting attention Manifest disorganized thinking Misinterpretations of environment –Easily distracted Perceptual disturbance (illusions, hallucinations…) Inability to remember immediate info Disorientation to time & place Change in speech Onset rapid Severity may fluctuate over course of day Mostly short duration but sometimes follows illness to death Sleep disturbance Change in psychomotor activity possible Anger, irritability, fear (often of hallucinations) FOR MORE INFO...

Associated Features Emotional disturbances Neurological signs –Dysgraphia Difficulty writing –Constructional apraxia Difficulty drawing –Dysnomia Difficulty naming objects Tremor Symmetrical increase or decrease in reflexes Autonomic hyperactivity

Predisposing Differential FactorsDiagnosis Advanced age (over 60) Drug dependence Preexisting Brain injury Schizophrenia Dementia Psychotic disorders Factitious disorder with psychological symptoms

Therapeutic Interventions & Treatment Identify and treat causative factors Recognize emergency situations Treat behavioral or psychiatric symptoms Environmental treatments Education of support system

Amestic Disorders Memory impairment –absence of other significant cognitive impairments Disturbance in memory –due to direct physiological effects of GMC –persisting effects of substance can be abuse –medication –toxin exposure

Amnesic Disorders Rare to last more than few months Amnesia –cannot learn new material –Cannot recall recent events although maybe remote past –Know self & name but not where at or what Some confabulation to fill gaps Unaware of memory deficits/denial May acknowledge but appear unconcerned Age & onset varies Common to head injury Evidence memory disturbance – consequence of medical condition or substance use

Causes Not part of delirium or dementia or intoxication or withdrawal Chronic heavy alcohol use Stroke Brain tumors Repeated or severe hypoglycemia – in poorly controlled diabetes Current or recent use of substance Damage to certain brain structures –caused by surgery, insufficient oxygen, cutoff of blood flow Infection

Treatment Psychiatric interview and assessment can reveal extent of memory loss Medial focus is treating underlying cause