Transcript Phenomenology Dementia Disorder of Cognitive Function The

Dementia
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Phenomenology
Dementia
P Disorder of Cognitive Function
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The Cognitive Functions
Attention and Concentration
Language function
Memory
Visuospatial Ability
Perceptual Capacity
Conceptualization and Abstract Reasoning
General Intelligence
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Dementia
Other aspects of The MSE
P General Presentation
varied with level
care taking
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Dementia
Other aspects of The MSE
P Emotions
Mood
B Generally euthymic
Bdysphoria, frustration early on
B May become Aagitated@ or Airritable@
Affect
B May be appropriate
B Blunted
B Inappropriate
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Dementia
Other aspects of The MSE
P Thought
Process
B impoverished
Content
B hallucinations rare
B > w/ Sensory impairment
B delusions
B poorly formed
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Neuritic Plaques
P Amyloid accumulation
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Tangles and Degeneration
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Delirium vs. Dementia
Things Different
PDeliriumBusually reversible
Dementia rarely so
PPathology
Dementia:
BUsually identifiable pathological findings
Bat least on autopsy
Delirium
Bmore often physiological
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Drugs approved for AD
• Cholinesterase Inhibitors
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Tachrine (Cognex)
donepezil (Aricept)
rivastigmine (Exelon)
galantamine (Reminyl)
• NMDA antagonists
– Memantine (Axura)
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Treatment of Dementia
Non-pharm. treatments
Psychosocial Treatments
B Provide structure
B Adjust to ability
Attention to the care givers
Education
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Child Psychiatry
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“A Child is a Psychotic Dwarf
with a Good Prognosis”
Anonymous Adult Psychiatrist
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Kids get it too…
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drug abuse
Depression
Mania
Anxiety
Schizophrenia
But full syndrome may not yet be present
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Same thing, different name:
• Conduct disorder = antisocial PD
• Identity dis.= borderline PD
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Early and only in C/A
• Reactive attachment
• Eating/elimination
• Separation anxiety
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Never in C/A
• Organic mental diseases of aging
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Early and Forever
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MR
Autism
LD
ADHD
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ADHD
• Inattention
• Hyperactivity and Impulsivity
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Inattention
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Cannot focus or sustain tasks
Careless mistakes
Poor organization
Forgetful, easily distracted
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Hyperactivity
• Hyperactivity
– Fidgety, gets up a lot.
– Runs, climbs, moves around inappropriately
– Talks a lot, Cannot quiet down.
• Impulsivity
– Blurts things out, can’t wait turn
– Interrupts.
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Epidemiology
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3-10%
Changing definitions
♂:♀ = 3:1
Increase of adult ADHD.
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Etiology
• Runsin families.
• Association with other disorders
– Mood, antisocial, substance abuse, learning.
• Possible link with mutation on D4 gene
– May make clinical sense
• Prenatal factors
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Imaging studies
• Decreased volume and hypoperfusion of
prefrontal and basal ganglia
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Course of ADHD
• Variable
• Abt ½ do well
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Treatment
• Pharmacological treatment
– Psychostimulants
• Amphetamines
• others
– Antidepressants
• TCAs
• bupropion
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Psychotherapies
• Behavioral therapy.
– Positive reinforcement
– Firm, nonpunitive limit setting.
• Environmental management
– Decrease distraction in the environment
• Education
– Of parents.
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Some general points about
psychotherapy in children.
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Use of Antidepressants
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1991 1992 1993 1994 1995 1996 1997 1998
Tricyclic
Newer atypicals
SSRI
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Dramatic Increase in Psychopharm
• everything is biological
• newer drugs are much safer
• you don't need the full diagnosis anymore (symptomatic
medicine)
– treating the partial syndrome (schizophrenia, mania, anxiety,
disorders, personality disorders).
• hello polypharmacy
– adjunctives
– nonspecific use (antipsychotics for agitation, mood stabilizers for
aggressivity, SSRI for "neurosis")
• "ask your doctor about Prozac“
• managed care
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Medications in Children
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psychostimulants (dx., abuse)
antidepressants (old and new)
antipsychotics (old and new)
anti-anxiety (addictive, the street)
mood stabilizers (all the rage, taper the antiseizure meds, slowly)
antiaggressivity (clonidine, tenex)
(autonomic, N.S. effect)
increase and decrease slowly
tapering side effects
can include serotonin-like syndrome, increased BP, withdrawal,
agitation, seizures, recurrence of psychotic symptoms
• the tendency toward non-compliance.
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