1. Neuropsychiatry and Memory (Dementias, Delirium)

2. Neuropsychiatry
Lishman - interface between neurology and psychiatry, concerned with disorders that can be demonstrated to owe their origins ‘to brain malfunction of a clearly identifiable nature’
Broadening of definition includes those which have no obvious / identifiable organic basis like conversion disorders (psychological and / or social basis)
Biological psychiatry – purely organic basis

3. Symptom assessment Easy to assess – basic motor and sensory functions
More difficult to assess – psychological symptoms – especially cognitive are easier to assess than emotional < personality < complex patterns of behaviours
Relating abnormalities of behaviour to precise aspects of cerebral pathology are limited in several important respects

4. Clinical picture
Different varieties of pathological change are often associated with similar forms of impairment
Dementia may result from anoxia, from trauma or from primary degenerative disease
Cornerstone of diagnosis in neuropsychiatry - extract important symptoms and syndromes
Cognitive impairment important symptom

5. Atypical presentations
Presentations with psychological symptoms alone
Well before the appearance of definite neurological signs
Often correct appreciation of these common forms of reaction that a mistaken diagnosis of non-organic (or so-called ‘functional’) psychiatric disorder will be avoided

6. Lady with panic attacks
35 year old lady presenting with panic attacks for past 2 years, not adequately improving with trials of SSRIs
No clear thyroid dysfunction or cardiovascular morbidity identified on initial investigations
However for past 2 years she has been detected to have HCV and rising viral loads
Now presented with spells of dizziness followed by acute onset right hemiplegia

7. 85 year old gentleman Living with grandson
History of being forgetful for over 2 years, progressive although fluctuating, increased food intake
Forgetting meals and conversations
At times not identifying people
Hard of hearing and vision impaired for past 3-4 years; Malunited Colles, immature cataract, pallor

8. Cognition
Memory, language, orientation, judgment, problem solving, interpersonal relationships, abstraction and performance of actions
Cognitive disorders have problems in these areas as well as behavioural symptoms
Delirium, neurocognitive disorder and amnesia

11. Symptoms
Memory impairment, especially recent memory • Aphasia • Apraxia • Agnosia • Executive function impairment - ability to think abstractly and plan such activities as organizing, shopping and maintaining a home

12. Delirium
Often refers to varieties of acute organic reaction, >40% of hospitalized elderly
Commonly acute onset, global cognitive dysfunction, often metabolic or substance
Prominent disturbances in alertness, as well as confusion and a short, fluctuating course, agitation or stupor, fear, emotional lability, hallucinations, delusions, and disturbed psychomotor activity

13. Symptoms
Diffuse cognitive deficits – attention, orientation, memory, visuo-constructional ability, executive functions
Temporal course – acute / abrupt
Perceptual alterations, thought and mood
Sleep-wake disturbances
Psychomotor activity

14. Delirium
Agitation or stupor, fear, emotional lability, hallucinations, delusions, and disturbed psychomotor activity, motor abnormalities, incontinence, evidence of underlying medical condition or substance-specific syndrome
Systemic infections, metabolic disorders, hepatic/renal diseases, seizures, head trauma
Substance intoxication / withdrawal

15. Delirium
EEG often shows generalized slowing of activity, fast-wave activity, or focal abnormalities
Managing requires reorienting periodically, care to prevent injuries, cautious use of physical restraint
Treating underlying condition
Antipsychotic – low dose for controlling agitation

16. Dementia
Memory disturbances coupled with other cognitive disturbances that are present even in the absence of delirium
Neurodegenerative disease (5% >65, 20% >85)
Cerebrovascular disease, trauma, infections, endocrinopathies, nutritional, toxins
Amnesia, increasing disorientation, anxiety, depression, emotional lability, personality disturbances, hallucinations, and delusions

17. Dementia
Duration – ICD specifies minimum of 6 month duration of cognitive deficits
Course may vary – stabilized cognitive dysfunction or progressive
On examination underlying medical condition may be manifest, often may have age-related or no physical signs
Screening – History and MSE, MMSE, HMSE

18. Dementia
EEG may have focal abnormalities, imaging- findings depend on the underlying etiology (generalized atrophy, subcortical white matter ischemic changes, infarcts)
Types – Alzheimer’s, vascular, mixed, other (Parkinson’s, huntington’s, Wilson’s, hypothyroidism)

19. Alzheimer
Most common; Risk factors - Female, family history, head trauma, Down syndrome
Cortical atrophy, flattened sulci, and enlarged ventricles
Senile plaques (amyloid deposits), neuronal loss, neurofibrillary tangles, synaptic loss, and granulovacuolar degeneration of neurons
Chromosome 21 – APP; depleting Ach

20. Alzheimer
Treatment includes long-acting cholinesterase inhibitors such as donepezil, rivastigmine, galantamine
NMDA modulator – memantine
Behavioral management, limited use of antipsychotic

21. Vascular
Male, advanced age, hypertension, or other vascular risk factors
Stepwise or gradual, focal neurologic symptoms, Carotid bruit, fundoscopic abnormalities, and enlarged cardiac chambers
Hyperintensities and focal atrophy
Control of risk factors - hypertension, smoking, diabetes, hypercholesterolemia, and hyperlipidemia

22. Frontotemporal dementia
Male predominant
Atrophy in the frontal and temporal lobes
Variants –PPA ( agrammatic, semantic, logopenic), behavioural variant
TDP-43, FUS, Tauopathy
Pick bodies (intraneuronal argentophilic inclusions) and Pick cells (swollen neurons)

23. Other causes Normal pressure hydrocephalus, hypothyroidism
Parkinson’s, lewy-body dementia
Huntington’s
Prion diseases
HIV infection

24. Reading list
Lishman’s organic psychiatry : a textbook of neuropsychiatry / Anthony David – 4th ed, 2009