Approach - Disturbed behaviour

Question 1

Describe schizophrenia

• positive symptoms
• negative symptoms
• cognitive symptoms
• functional symptoms
• impaired insight

Answer 1

–Positive symptoms: delusions, hallucinations, disorganisation
–Negative symptoms: affective blunting, anhedonia, amotivation/avolition, poor self care, social withdrawal, alogia
–Cognitive symptoms: executive dysfunction, memory, other
–Functional symptoms: work/study, relationships/family, personality
–Impaired insight: illness, treatment, impact etc

Question 2

Describe 3 types of delirium (in terms of its activity)

Answer 2

1. Hyperactive delirium ~ 30%
   •easily recognised
   •repetitive behaviours (e.g. plucking at sheets), wandering, hallucinations or verbal and physical aggression
2. Hypoactive delirium ~ 25%
   •easily missed
   •patients appear quiet and withdrawn and may be misdiagnosed as depressed
3. Mixed pattern ~ 45%
   •fluctuates and includes lucid periods

Question 3

List predisposing factors for delirium (c.f. precipitating factors)

Answer 3

Increased age

Pre-existing cognitive deficits:

• Dementia
• Past cerebral damage

Polypharmacy Sensory impairment &/or deprivation

Multiple chronic medical conditions

Question 4

List (6) types of precipitating factors for delirium & their examples (c.f. predisposing factors)

Answer 4

1. Medications: intoxication, action, side effects & interactions
2. Severe/multiple medical problems:
   - Infection/sepsis
   - Metabolic encephalopathies
   - Dehydration/poor nutrition
   - Electrolyte imbalance
   - Organ failure
   - Hypoxia
   - Fever/hypothermia
3. Surgery & anaesthetics: especially emergency, lengthy & orthopaedic procedures
4. Substance withdrawal: especially alcohol & benzodiazepines
5. Acute brain pathology
6. Environmental aspects:
   - Disturbed sleep
   - Urinary catheter
   - Pain & discomfort
   - Unfamiliar environment
   - Immobility
   - Restraints
   - Absence of sensory aids

Precipitating factors must be treated to treat delirium

Question 5

How do you diagnose delirium?

Answer 5

by CAM (Confusion assessment method)

Dx of delirium requires both:

• Acute onset and fluctuating course
• Inattention

AND
- Disorganised thinking
OR
- Altered conscious state

Question 6

Describe dementia

• cognitive deficits
• non cognitive deficits
• BPSD

Answer 6

–Cognitive deficits include memory, executive function, language
–Non-cognitive deficits include mood and behavioural symptoms, often referred to as BPSD

• BPSD: behavioural and psychological symptoms of dementia

“symptoms of disturbed perception, thought content, mood or behaviour that frequently occur in patients with dementia”

Question 7

Interpret the score of MMSE

Answer 7

25-30 normal
21-24 mild cognitive impairment
14-20 moderate cognitive impairment

Question 8

DDx of dementia

Answer 8

• Alzheimer’s Disease
• Other dementias (Frontal lobe dementia, Creutzfeldt-Jakob disease, HIV, alcohol)
• Dementia with Lewy bodies (PD, Diffuse Lewy Body disease)
• Vascular dementias

Question 9

Compare & contrast delirium from dementia

• onset
• duration
• presence of other disorders/physical problems
• variation at night
• attention
• level of consciousness
• memory
• need for Rx

Answer 9

Delirium:

• sudden onset
• days to weeks
• other disorders/physical problems almost always present
• almost always worse at night
• impaired attention
• fluctuating level of consciousness
• jumbled & confused memory
• emergency medical condition

Dementia:

• slow onset
• months to years
• possibly no presence of other disorders/physical problems
• often worse at night (“sundowning”)
• attention maintained until late
• normal level of consciousness until late
• lost memory (esp recent)
• non medical emergency