Introduction Medical Psychiatry: Cognitive Disorders and Delirium: A syndrome, not a disease Many underlying causes Somatoform Disorders Reversible global impairment of cognitive processes Impairment of: consciousness, Cynthia L. Gauss, MD cognitive function, awareness VCU School of Medicine Inova Campus 1 2 Disturbed Functioning Time Course Cognitive: perceiving, thinking, Rapid onset – hours to days remembering Brief fluctuating course Arousal and attention: involves Rapid resolution, once underlying reticular activating system causes identified and treated Psychiatric symptoms: mood, perception, and behavior Patients with delirium: longer Neurologic symptoms: asterixus, hospital stays, more likely to die nystagmus 3 4 Many Different Names Epidemiology Delirium is a common disorder Acute brain syndrome General population: 0.4% age 18 and Acute confusional state older, 1.1% age 55 and older Metabolic encephalopathy 10-30% hospitalized medically ill Toxic psychosis 30% surgical and cardiac ICU pts. Toxic encephalopathy 40-50% patients s/p hip surgery Sundowning 90% postcardiotomy patients ICU psychosis 30-40% hospitalized patients with AIDS 5 6 1 Risk Factors Other Risk Factors Age: 30-40% hospitalized elderly Pre-existing brain damage Pain History of delirium Malnutrition Alcohol, drug dependence Dehydration Poor mobility Diabetes Cancer Sleep deprivation Sensory impairment Male gender Young children 7 8 Etiology CNS Causes Central nervous system illness Epilepsy Systemic disease, metabolic Brain trauma disturbance Meningitis Intoxication or withdrawal from Tumor substances or medications Vascular disease 9 10 Systemic Illness Drugs, Poisons Anticholinergic Endocrine Vitamin Phencyclidine dysfunction deficiencies Anticonvulsants Phenytoin Antihypertensive Liver (hepatic Infection Ranitidine encephalopathy) (fever,sepsis) Antiparkinsonian Salicylates Antipsychotics Kidney (uremic Electrolyte Opiates Cardiac glycosides encephalopathy) imbalance Sedatives Cimetidine Lung disease Trauma (head, Steroids Clonidine Cardiovascular body) Disulfiram Heavy metals disease Postoperative Carbon monoxide states Insulin 11 12 2 DSM-IV-TR Criteria Of Pathophysiology Delirium Cholinergic dysfunction: possible Disturbance of consciousness (i.e., common denominator reduced clarity of awareness of the Excess dopamine: believed to lead to environment with reduced ability to agitation, psychosis focus, sustain or shift attention) Involvement of reticular activating formation leads to problems with attention 13 14 DSM-IV-TR Criteria Of 5 Types Delirium Delirium due to a general medical A change in cognition (such as memory condition deficit, disorientation, language Substance intoxication delirium disturbance or the development of a perceptual disturbance that is not better Substance withdrawal delirium accounted for by a preexisting established Delirium due to multiple etiologies or evolving dementia. The disturbance develops over a short Delirium not otherwise specified period of time (usually hours to days) and (unknown cause or due to causes tends to fluctuate during the course of the not listed, such as sensory day. deprivation) 15 16 Diagnosis Other Diagnostic Features Most significant features: Disturbed psychomotor behavior – Decreased and fluctuating levels of Disturbance of sleep/wake cycles consciousness Mood alterations – Disturbance of attention Perceptual disturbance – Disorientation – Memory disturbance Disturbed thought processes Neurological abnormalities 17 18 3 Diagnostic Procedures Diagnosis Mental status exam, including mini- The main goal is to determine and mental status exam treat the underlying medical cause of the delirium. Longitudinal, systematic clinical assessments Physical exam Laboratory data 19 20 Laboratory Data Differential Diagnosis Blood chemistries: Chest X-ray electrolytes, renal Drug screen Dementia and liver fx, EEG: slow waves glucose Brief psychotic disorder Blood, urine and Schizophreniform disorder CBC with diff CSF cultures Thyroid function B12 and folate Mood disorders RPR CAT scan of brain Anxiety disorders Urinalysis Lumbar puncture Malingering HIV EKG 21 22 Course And Prognosis Treatment Sudden onset Resolves over hours to weeks After treating underlying causes, The primary aim of treatment: treat usually resolves in 3-7 days the underlying medical cause of the delirium Most recover Treat the symptoms of delirium Others progress to stupor, coma or seizures Provide a safe and supportive environment 20-75% die during hospitalization 25% die within 6 months 35% die within a year 23 24 4 Pharmacologic Treatment Behavioral Management Ensure safety: fall prevention, Minimize polypharmacy in general remove dangerous items, 1 to 1 Check medication levels sitter, avoid restraints Treat psychosis with Haldol (po and Consistent staff, family, friends IM) or atypical antipsychotics: Calm environment: avoid sensory Risperdol (po,IM,m-tabs) Zyprexa deprivation and over-stimulation (po, zydis, IM), Geodon (po, IM) or Regular orientation, explanations, Seroquel reassurances Avoid benzodiazepines alone, except Provide calendars, familiar objects, for alcohol, sedative withdrawal 25 nightlight, glasses, hearing aid 26 Dementia Epidemiology Global decrease of cognition in 8 to 10% over 65 develop dementia multiple domains 40% over age 80 develop dementia Stable level of consciousness Dementia of Alzheimer’s type Due to abnormalities in brain structure increases in prevalence with age Risk increases with age Annual cost: 80 to 100 billion $/year Leads to institutionalization 50% of nursing home patients have Often permanent Alzheimer’s 15% of dementias are reversible if 2 million people in nursing homes treated with dementia 27 28 Epidemiology Etiology Dementia most commonly occurs Alzheimer’s dz Nutritional (B12, after age 60 Vascular dementia folate, thiamine Rare cases occurs in 40s or 50s Drugs, toxins deficiency, pellagra) (early-onset dementia) (including alcohol) Anoxia Alzheimer’s is leading cause Tumors Normal-pressure hydrocephalus Vascular dementia 2nd leading cause Infections (Creutzfeld-Jacob, Head trauma The two together make up 75% AIDS, neurosyphilis, Inflammatory dz meningitis) (Lupus, MS) 29 30 5 Etiology Diagnosis: DSM-IV-TR Neurodegenerative Metabolic Dementia of the Alzheimer’s Type Disorders: disorders: Vascular dementia (Multi-infarct – Parkinson’s disease – Leukodystrophies dementia) – Huntington’s dz – Dialysis dementias Dementia due to a general medical – progressive – Renal insufficiency supranuclear palsy – Hepatic insufficiency condition – Pick’s disease – Hypo- and hyper- Substance-induced persisting – Wilson’s disease thyroidism dementia – Cushing’s syndrome Dementia due to multiple etiologies Dementia not otherwise specified 31 32 DSM-IV-TR Criterion DSM-IV-TR Criterion The development of multiple – One (or more) of the following cognitive cognitive deficits manifested by disturbances: • aphasia (language disturbance) both: • apraxia (impaired ability to carry out motor – Memory impairment (impaired ability to activities despite intact motor function learn new information or to recall • agnosia (failure to recognize or identify objects previously learned information) despite intact sensory function) • disturbance in executive functioning (ie, planning, organizing, sequencing, abstracting) 33 34 DSM-IV-TR Criterion Diagnosis Clinical examination: mental status and physical exam The cognitive defects in Criteria A1 Comprehensive history from pt, family and A2 each cause significant Memory, problems with behavior and impairment in social or occupational functioning, mood and personality functioning and represent a changes significant decline from a previous Mini-mental status exam (Folstein’s) level of functioning. Need a baseline score The deficits do not occur exclusively Widely used, can compare between during the course of a delirium. different clinicians, and as illness progresses 35 36 6 Laboratory Work-Up Psychiatric Symptoms Personality changes CBC Chest X-ray Hallucinations and delusions Chemistries: EKG Mood changes: anxiety and Electrolytes, renal CT or MRI of brain and liver function depression SPECT or PET of “Pseudodementia” B12, folate brain Dementia can co-exist with Urinalysis Neuropsychologic RPR (syphilis) al testing depression HIV Dementia is a risk factor for depression 37 38 Alzheimer’s Dementia Alzheimer’s Dementia Continuing and gradual decline Onset: ages 40-90 Definitive diagnosis: brain autopsy Early onset < age 65 Senile plaques (amyloid) Late onset > age 65 Neurofibrillary tangles Apolipoprotein E (APOE) 4 allele: Early onset linked to chromosome increased risk mutations 1, 14, 21 Systemic and other brain diseases Confirmatory testing: SPECT or PET need to be ruled out scan, APOE-4, presenilin 39 40 Vascular Dementia Lewy Body Disease Associated with arteriosclerosis Clinical features similar to Cannot make diagnosis without Alzheimer’s clinical evidence (focal neurological Early onset visual hallucinations and signs) or evidence from brain parkinsonism imaging Lewy bodies: eosinophilic inclusions Often abrupt deterioration in neurons throughout the cortex Fluctuating, step-wise progression Patients very sensitive to typical Associated with HTN, diabetes, antipsychotics stroke 41 42 7 Fronto-Temporal Dementia Pharmocologic Treatment (Pick’s