Cognitivie impairment Flashcards
Whagt is cognition
- Cognition = defined as ‘the mental action or process of acquiring knowledge an understanding through though, experience an the senses…The ability to perceive and react, process and understand, store and retrieve info, make decisions and produce appropriate responses
- The essential qualities your brain utulises to think, listn, learn, understand, jsutify, question and pay close attention.
Cognitive domains
What is cognitive impairment?
- not an illness, but a description of osmeones ocndition
- Cognitive impairment means an individual ay hvae trouble with things like memory or paying attention, trouble speaking or understanding, some people have difficulty recgonisign others, places or things.
- Cognitive impairment can occur with a range of severities and there are many causes
ICD-10 Organic mental disorders F00-F09 organic, including symptomatic, mental disorders
Aetiologicla factors of cognitive impairments
Assessment of the ‘confused’ patient; hsitory, examination & assessment of patients with delerium and dementia
Also:
- Signficiant phsycial healht problems: alertness, falls, motor ysmptoms, signs for infecton
- FH of dementia and psychiatric conditions
- Personal hsitory (occupations - boxign), alcohol
- PMH: delerium, head injury, CV disease, angina, parkinsons, tumour. Diabaters, hypercholesterolemia (vasuclar demetia
- Pats psychiatric hsitory (mild congnitive impairment, depression = pseudo dementia)
- Drug & medication history (drugs & cognitive impairment)
- Premorbid personality: alcoho
Physical examination findings: examples of abnormal neurological signs and significance in dementia.
Inevstiagtions in cognitive imapirment
Examinations (and tests) in cognitive impairment
- Physical exam
- Relevent neurological system exam
- Mental state exam
- Cognitive teste- MMSE, MoCA ACE-II
- Brain imaging
- Neuropsychology assessment
Some aetiologival RFs in Dementia
- Age
- Genetics / family history.
- Vascular risks ( stroke, atherosclerosis, Hypertension, Cholesterol, type 2 diabetes )
- Parkinson’s disease.
- Depression.
- Mild cognitive impairment.
- Down’s syndrome
- Head injury.
- Heavy alcohol consumption.
Some causes of Dementia
Common main subtypes of dementia
Neuroimaging in dementia
- Detecting potentially reversible causes of dementia.
- Detecting and assessing cerebrovascular disease.
- Improving early diagnosis of neurodegenerative diseases, particularly Alzheimer’s disease by quantification of atrophy.
- Identify rare and untreatable diseases with distinctive neuroimaging signatures( e.g. leucodystrophies, variant Creutzfeldt-Jakob disease, limbic encephalitis etc.)
AD: Neuroimaging (CT Brain scan)
Control vs Dementia
Nueorimaging (MRI) head for dementia
DAT Scannromal vs parkinsonism
SPECT (Blood perfusion) - normla, alzheimers, PICKs
Cogntiive assessments
3 Types of Delerium
Hyperactive (classical):
- Increased sympathetic activity, agitation
- Restless and disturbed sleep cycle
- Rapid mood changes and hallucinations
- Most easily recognised
Hypoactive (underdiagnosed):
- Poor oral intake - need feedign an duspervision with meds
- Wors eprognosis - prone to malnutrition and dehydration
- Inacti ity or reduced motor activity
Mixed (most common):
- FLuctuates - hyperactivity evident at night- lack insight and recollection durign the day
- Switch/ fluctuates from hypoactive to hyperactive states
Causes of Delirium
- Metabolic encephaloapthies (eg, endocrine disorders, hypoglycaemia)
- Intoxication by drugs or posions (eg, digoxin, alcohol, ilicit, drugs)
- Withdrawal syndromes - alcohol, hypnotics- sedatives
- Infections, both intracranial (meningitis, encephalitis) and systemic
- Multifocal and diffuse brian disease (Hydrocephalous, anoxia, cerebrovascular disease
- Head trauma
- Epilepsy
- Focal brain lesions (brian stem or right hemisphere)
Predisposing and precipitating RFs to delerium
Delerium Core features
- Reduced awareness of the environment
- Poor thinking skills (cognitive impairment)
- Behaviour changes
- EMotional disturbance
clinicla signs and symptoms in delerium (acute confusion)
- Reduced ability to maintain / shift attention
- Disorganized thinking ( rambling, irrelevant, incoherent speech)
- Memory impairment : poor registration & retention
- Perceptual distortions ( misidentifications, illusions, hallucinations)
- Fear or Paranoia.
- Increased / decreased psychomotor activity. Restlessness / agitation.
- Slowed movement, Withdrawn & lethargy.
- Disturbed sleep wake cycle
- Disorientation in time, and often in place.
- Changes in mood & personality (irritability, anxiety, depression & liability)
- Fluctuations & nocturnal exacerbation. Disturbed sleep habits.
Assessing and diagnosing delerium
Confusion Assessment Method (CAM):
Sensitivity 94% and specificity 90-95%
Consider delirium if 1 and 2 and 3a or 3b are positive
- 1) Acute onset and fluctuating course (Acute change in mental state from normal baseline. Does the abnormal behaviour fluctuate during the day (come and go or increase and decrease).
- 2) Inattention (Difficulties focussing attention e.g. distractible and or difficulty keeping track)
- 3a) Disorganised thinking (Rambling or irrelevant conversation, unpredictable switching from subject to subject/illogical flow of ideas)
- 3b) Altered level of consciousness (Level of consciousness, alert, vigilant, lethargic, stupor, coma)
Criteria for Diagnosis
- Distrubance of consciousness with reduced ability to focus, sustain or shfit attention
- A change in cognition/development of a perceptual disturbance that is not accounted for by a pre-existig dementia
- Develops quickly and fluctuates durign the course of the day
- Physiological cause
Management of delerium key points
- Awareness & risk factor assessment.
- Supportive care to prevent complications.
- Interventions to prevent (e.g. Environment / disorientation, mobility, nutrition, rehydration, oxygen saturation, pain, medication review, sleep hygiene, sensory impairment, addressing incontinence , avoiding physical restraint etc.)
- Look for and treat the underlying cause
- Effective communication & reorientation
- Non verbal de-escalation techniques.
- Caution with antipsychotic medication (haloperidol, olanzapine)used for distressing symptoms e.g. agitation, hallucinations & improve sensory problems).
- Can take up to 6 months to resolve
- Risk of further delirium increases with episodes.
Potential risks in patients with cognitive impairment and dementia
- Impaired activities of daily living ( kitchen appliances, personal care / self neglect)
- Agitation, restlessness, aggression.
- Abnormal perception & psychosis
- Reduced mobility & falls
- Wandering & getting lost.
Poor medication compliance
- Physical health decline
- Driving
- Financial issues
- Vulnerabilities with risk of exploitation (sexual disinhibition)
- Depression ( suicidal thoughts )
- Carers stress.
- Challenging behaviour.
- Inadequate nutritional intake.
Principles of management in cognitive impairment: dementia
Management approaches in cognitive impairment: dementia
Dementia and delerium quiz
