Cognitive Disorders

Question 1

Dementia

Answer 1

Decline in cognitive functioning with global deficits. Level of consciousness is stable (vs delirium). Prevalence is highest among those greater than 85 years of age. The course is persistent and progressive. The most common causes are Alzhemier’s (65%) and vascular dementia (20%). Other causes are remembered with “DEMENTIAS”

1) Degenerative diseases (Parkinson’s, Huntington’s)
2) Endocrine (Thyroid, parathyroid, pituitary, adrenal)
3) Metabolic (Alcohol, electrolytes, B12 def, glucose, hepatic, renal, Wilson’s Disease)
4) Exogenous (heavy metals, carbon monoxide, drugs)
5) Neoplasia
6) Trauma (subdural hematoma)
7) Infection (Meningitis, encephalitis, endocarditis, syphilis, HIV, prior diseases, Lyme disease)
8) Affective disorders (pseudodementia)
9) Stroke/Structure (vascular dementia, ischemia, vasculitis, normal pressure hydrocephalus)

Question 2

History and physical for dementia

Answer 2

Diagnostic criteria include memory impairment and 1 or more of the following

1) The 4 As of dementia (progression of cognitive impairment follows this order). Amnesia (partial or total memory loss), Aphasia (language impairment), Apraxia (inability to perform motor activities), Agnosia (inability to recognize previously known objects/places/people)
2) Impaired executive function (problems with planning, organizing, and abstracting) in presence of a clear sensorium
3) Personality, mood, and behavior changes are common (wandering and aggression)
4) Patients often can become more confused late in the day and at night (sundowning)

Question 3

Diagnosis of dementia

Answer 3

1) Careful history and physical. Serial MMSE

2) Rule out treatable causes. Get CBC, RPR, CMP, TFTs, HIV, B12/folate, ESR, UA, head CT or MRI

Question 4

Tx of dementia

Answer 4

1) Provide environmental cues and a rigid structure for the patient’s daily life
2) Cholinesterase inhibitors are used to treat. Low dose antipsychotics may be used for psychotic symptoms and sometimes for agitation, but with the added risk of cardiovascular events in elderly patients. Avoid benzos which may exacerbate disinhibition and confusion
3) Family, caregiver, and patient education and support

Question 5

Delirium

Answer 5

Acute disturbance of consciousness with altered cognition that develops over a short period of time (usually hours to days). Children, the elderly, and hospitalized patients (ICU psychosis) are particularly susceptible. Symptoms are potentially reversible if underlying cause can be treated

Major causes of delirium are I WATCH DEATH

1) Infection
2) Withdrawal
3) Acute metabolic/substance Abuse
4) Trauma
5) CNS pathology
6) Hypoxia
7) Deficiencies
8) Endocrine
9) Acute vascular/MI
10) Toxins/drugs
11) Heavy metals

Note: It is COMMON for delirium to be superimposed on dementia

Question 6

History and exam for delirium

Answer 6

1) Presents with acute onset of waxing and waning consciousness with lucid intervals and perceptual disturbances (hallucinations, illusions, delusions)
2) Patients may be combative, anxious, paranoid, or stuporous
3) Also characterized by a decreased attention span and short-term memory, and a reversed sleep-wake cycle

Question 7

Dx of delirium

Answer 7

1) Check vitals, pulse ox, and glucose; perform physical and neuro exams
2) Note recent meds (narcotics, anticholinergics, steroids, or benzos), substance use, prior episodes, medical problems, signs of organ failure (kidney, liver) and infection (occult UTI is common in elderly so check UA)
3) Order lab and rads studies to ID a possible underlying cause

Question 8

tx of delirium

Answer 8

1) Treat underlying causes (delirium is often reversible)
2) Normalize fluids and lytes
3) Optimize sensory environment and provide needed visual and hearing aids
4) Use low-dose antipsychotics (haldol) for agitation and psychotic symptoms
5) Conservative use of physical restraints may be needed to prevent harm to patient or to others