L7: Neurocognitive Disorders & Psychiatric Disorders Due To GMC Flashcards
what is cognition?
Cognition includes:
- memory
- language
- orientation
- judgment
- conducting interpersonal relationshij
- performing actions (praxis)
- problem solving
Cognitive disorders reflect disruption in one or more of these domains and are frequently complicated by behavioral symptoms.
what are major neurocognitive disorders?
- Delirium
- Dementia
Def of Delirium
- It is a state of acute organic brain dysfunction.
Characters of Delirium
- Short-term confusion.
- Acute onset of fluctuating cognitive impairment.
- Disturbance of: consciousness, perception and other cognitive functions with reduced ability to attend.
Epidemeology of Delirium
Causes of Delirium
CP of Delirium
Course & Prognosis of Delirium
- The symptoms of delirium usually persist as long as the cause is present.
- Generally, lasts less than a week.
- After treatment of the cause, the symptoms of delirium usually regress over a 3- to 7-day period.
- The occurrence of delirium is associated with a high mortality rate in the following year.
DSM 5 Criteria of Delirium
DDx of Delirium
what is the major difference between dementia and delirium?
- demented patients are alert without the disturbance of consciousness characteristic of delirious patients.
Delirium can be distinguished from psychotic symptoms by …..
the abrubt development of cognitive deficits including disturbance of consciousness.
TTT of Delirium
It is a medical emergenct BTW
Delirium is commonly experienced by ……
patients in ICU and postoperative recovery.
Generally avoid using ………… to treat delirium. These medications often worsen delirium by causing paradoxical disinhibition or oversedation. Prescribe only in the case of delirium due to alcohol or benzodiazepine withdrawal.
benzodiazepines
what are the causes of Dementia?
Drugs that cause delirium include:
Tricyclic antidepressants, Anticholinergics, Benzodiazepines, Opioids and H2 blockers.
what is Dementia?
(Chronic progressive cognitive decline)
Overview of CP of Dementia
Epidemeology of Dementia
The prevalence of dementia increases with age:
- 5% of patients over 65 years old have dementia.
- but after age 85, 20%:40% of the population is affected.
Clinical features of Dementia
DSM5 Criteria of Alzehimer Type Dementia
The patient meets basic diagnostic criteria for dementia but also:
- Gradual onset and continued cognitive decline.
- Cognitive deficits are not due to another medical condition or substance.
- Symptoms are not caused by another psychiatric disorder.
DSM5 Criteria of Dementia
Neuropathology of Alzehimer Type Dementia
- Amyloid plaques
- Neurofibrillary tangles
Classification of Alzehimer Type Dementia
- Early or late onset.
- With delirium, delusions, depressed mood, or uncomplicated (complicated or
Amyloid plaques in Alzehimer Type Dementia
What do Neurofibrillary tangles consist of?
insoluble twisted fibers
average life expectancy after onset of Alzehimer Type Dementia
8-10 years
Site of Neurofibrillary tangles
inside of the brain’s cells (not between them i.e. not outside).
what do Neurofibrillary tangles primarly consist of?
- They primarily consist of a protein called tau, which forms part of a structure called a microtubule.
- The microtubule helps transport nutrients and other important substances from one part of the nerve cell to another.
abnormality in Neurofibrillary tangles in Alzehimer disease?
In Alzheimer’s disease, however, the tau protein is abnormal (become phosphorylated) and the microtubule structures collapse leading to brain atrophy.
Three genes confer a predisposition for the …….. onset (pre-senile) form of AD:
Early
- Amyloid precursor protein (APP) [located on chromosome 21,so associated w dawn syn.]
- Presenilin 1
- Presenilin 2
One gene increases risk for …… onset AD
Late
- ApoE4: E4 allele associated with more risk; E2 allele may reduce risk.
All genes impaiments in Alzehimer Disease affect ……..
Beta Amyloid
Relation between Alzheimer Disease & Environment
- Tangles (but not plaques) can be produced by exposure to high levels of aluminum.
- Tangles often cluster around blood vessels (suggests a toxic factor carried by blood).
Alzheimer Disease & Neurotransmitters
Ach in Alzheimer Disease
- Degeneration of the neurons of nucleus basalis of Meynert.
- Decrease of brain conc. of Ach and choline acety! transferase
- Cognitive impairment of anticholinergic drugs
NE in Alzheimer Disease
Decrease of NE neurons in the locus ceruleus.
Alzheimer Disease & Estrogen
- Risk for Alzheimer’s Disease among women is twice that of men (F:M =2:1)
- Hormone replacement therapy for postmenopausal women reduces life-time risk to that of men (HRT+postmenopausal - F= M)
- Hormonal replacement therapy does carry increase risk for breast cancer, endometrial cancer and gall bladder disease.
Alzheimer Disease & Neuroimaging
Sequential destruction in brain areas in Alzheimer Disease
There is a sequential destruction of brain areas that control memory function, then emotion and inhibition, and finally sensation.
what does Alzheimer Disease spare?
regions that control vision and other functions that remain intact in Alzheimer’s patients.
How much grey matter do patients with Alzheimer Disease lose per year?
- Alzheimer’s patients lost an average of 5.3% of their gray matter per year.
- Brain cells were purged even faster in memory regions, where patients lost up to 10% a year.
- In contrast, healthy elderly volunteers lost only 1% of their brain tissue annually.
what is the old name of Vascular Dementia?
Multi-Infarct Dementia
Importance of Neuroimaging of Alzheimer Disease
This method will be used to reveal how drugs and vaccines combat the wave of brain damage caused by Alzheimer’s disease.
DSM5 Criteria of Vascular Dementia
Causes of Vascular Dementia
- Multiple infarcts
- Subacute bacterial endocarditis
- Congestive heart failure
- Collagen vascular diseases (e.g., SLE)
DSM5 Criteria of Dementia of GMC
Meets basic diagnostic criteria for dementia, but there must also be evidence that symptoms are the direct physiological consequence of a general medical condition.
DDx of Dementia
- Delirium
- Amnestic Disorder
- Pseudodementia
Compare between Delirium & Dementia
what are Amnestic Disorders?
Characterized by isolated memory disturbance, without the cognitive deficits seen in dementia.
Pseudo Dementia
Lab Evaluation of Delirium & Dementia
- Complete blood chemistry.
- CBC with differential.
- Thyroid function tests.
- Urinalysis.
- Drug screen.
- Serum levels of all measurable medications.
- Vitamin B12 level.
- Heavy metal screen.
- Serological studies (VDRL or MHA-TP).
- EKG.
- Chest X-ray.
- EEG.
- Brain Imaging (CT, MRI) is indicated if there is a suspicion of CNS pathology, such as a mass lesion or vascular even.
Clincal Evaluaton of Delirium & Dementia
- All patients with cognitive deficits should be evaluated to determine the etiology of the dementia, Some [not all] causes of dementia are treatable and reversible.
Clinical Evaluation:
1- Medical history and a physical examination, with special attention to the neurological exam, should be completed.
2- Psychiatric evaluation (history & Examination)
3- Cognitive evaluation by MMSE: score < 25-24 implies cognitive impairment, which may suggest dementia or delirium.
what is Mild Cognitive Impairment (MCI)?
Memory in:
Normal aging Vs Alzheimer Disease
Managment of Dementia
- Any underlying medical conditions should be corrected.
- The use of CNS depressants and anticholinergic medications should be minimized.
- Patients function best if highly stimulating environments are avoided.
- The family and/or caretakers should receive psychological support in the form of support groups, psychotherapy, and day-care centers.
General Rules of Pharmacological TTT of Dementia
- Start low and go slow.
- Cognitive enhancers.
- Anti-psychotics, anti-depressants and short half live benzodiazepines could be used for symptomatic relief of psychiatric symptoms.
Pharmacological TTT of AD Dementia
Pharmacological TTT of Vascular Dementia
- Hypertension must be controlled.
- Aspirin may be indicated to reduce thrombus formation
- Cognitive enhancers may have some role
Non Pharmacological treatment of Dementia
- Simplify the daily routine
- Improve the environmental cues and continuous patient orientation
- Protection from dangers or loss
- Education and support of care
Def of Psychiatric Disorders due to GMC
what are GMCs That may cause Psychiatric Disorders?
- Trauma (head injury).
- Cardio vascular diseases.
- Tumors.
- Intoxications.
- Nutritional diseases.
- Metabolic.
- Endocrine disorders.
- Infectious diseases including HIV infections.
- Autoimmune disorders.
Psychiatric Complications of Endocrine Disorders
what are Psychiatric Disorders due to GMC?
- Delirium.
- Dementia.
- Amnestic disorder.
- Psychotic disorders.
- Mood disorders.
- Anxiety disorders.
- Catatonic disorders.
- Personality changes.
- Mental disorders NOS.
Features Suggesting a medical origin of a Psychiatric disorder
- Late onset of initial presentation
- Known underlying medical condition
- Atypical presentation of a specific psychiatric diagnosis
- Absence of personal and family history of psychiatric illness
- Illicit substance use
- Medication use
- Treatment resistance or unusual response to treatment
- Sudden onset of mental symptoms.
- Abnormal vital signs
- Waxing and waning mental status
Managment of Psychiatric Disorders due to GMC
