Transcript Cognitive DisordersRevisions

Cognitive Disorders
Delirium
Dementia
Amnestic Disoders
Characteristics
•These disorders are not developmental
•Delirium and dementia often appear together
•One may be imposed upon the other
•Symptoms are consistent with one of the
recognized syndromes of cognitive impairment
•Search for an underlying physiological cause
for the symptoms
•Assess using a team-based approach
Diagnostic Process
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Symptoms consistent with
recognized cognitive
impairment
 Search for underlying
physiological cause
 Team based assessment
Recording Procedures
Axis I – presence of cognitive problem due
to general medical condition
 Axis III – underlying medical problem with
ICD number
 Provisional diagnosis – if unclear what
cognitive deficits due to
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With dementia:
Note if there is a behavioral disturbance
Superimposed
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If in progression of existing dementia
– delirium develops
• subtype is noted
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An example
– Dementia, Alzheimer’s type, late onset, with
Delirium
• Dementia diagnosed 1st, the delirium arrived
Differences
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Delirium
– Disturbance in consciousness accompanied
by widespread brain dysfunction
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Dementia
– Distinguished by impairment in memory
• sort or long term
• recent & remote
– Also impairment of 1 other brain function
Exhibit signs & symbols of global brain dysfunction
Dementia
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Can be referred to as senility, gradual
deterioration of intellectual abilities to where it
impairs social and occupational functioning
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Multiple cognitive deficits which are skill
oriented, indicate global brain dysfunction
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Easier to diagnose than delirium
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Clients may present with cognitive
disturbances
Dementia
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May be caused by:
– nonpsychiatric medical condition
– a substance or
– mixture
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Terms
– Aphasia – inability to understand or
produce language
– Apraxia – loss of motor skill
– Agnosia – problems with visual &
spatial
Causes of Dementia
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Over 70 possible causes
Alzheimer's
– diagnosed only by ruling other things out
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Primary dementias
– produced directly by brain impairment
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Secondary dementias
– caused by diseases not attacking brain directly
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Depression
Hormonal imbalances
Drugs
Arteriosclerosis
Pneumonia
HIV
etc
What Does Dementia Look Like?
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Early progression
– Client may be aware of deficits
Numerous Attempts to hide
– Rigid patterns for daily life
– Avoid departure from routine
Denial
– including family
No typical case
– Signs/symptoms vary greatly
– Depends on cause, course, severity of underlying disease or problem
– Region of brain affected looks different
– Personality before dementia
MSE focus
– Memory loss
– Difficulty with problem solving
– Language
– Vision-spatial coordination
– Numbers
Differential Diagnosis - Dementia
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Consider:
– Normal aging
– Delirium
– Schizophrenia
– Major depressive disorder (depressive
pseudodementia)
– Factitious disorder with psychological symptoms
 Females are most misdiagnosed
 Important to look at dementia vs. depression
Dementia versus Depression
Both may have poor judgment, somatic complaints, & psychotic behaviors
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In Dementia
– Memory deficits
– Perseveration
– Affect is
“suggestible”
– Affect is
inconsistent
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In Depression
– Difficulty in
concentration
– Difficulty learning
new information
– Affect is not
influenced by
others
– No cognitive
disturbances
Dementia: Treatment Possibilities
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Depends on type of dementia
diagnosed
 No treatment for biological component
 Find cause and attempt to treat it first
 Focus on client management and
environment
 Some types of medication may help
 Counseling for client and support
group
Delirium
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Disturbance of consciousness & change
in cognition
 Decline from higher functioning
 Impairment in occupational or social
functioning
 Difficulties with assessment
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Need medical tests
Accurate MSE
Accurate history
Primary cause may no longer be present
Children more susceptible to delirium from
meds
Often misdiagnosed
Causes of Delirium
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General medical
– Fever
– Hypoxia
(lack of oxygen)
– Ischemi (lack of blood flow to brain)
– brain infections such as meningitis
 Persisting effects of substance
– Many medications & drugs can cause delirium
during or after use
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Seizure or traumatic brain injury
 Multiple etiologies
What does delirium look like?
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Cannot concentrate
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Manifest disorganized thinking
Misinterpretations of environment
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Difficulty maintaining or shifting attention
Easily distracted
Perceptual disturbance (illusions, hallucinations…)
Inability to remember immediate info
Disorientation to time & place
Change in speech
Onset rapid
Severity may fluctuate over course of day
Mostly short duration but sometimes follows illness to death
Sleep disturbance
Change in psychomotor activity possible
Anger, irritability, fear (often of hallucinations)
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Associated Features
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Emotional disturbances
Neurological signs
– Dysgraphia
• Difficulty writing
– Constructional apraxia
• Difficulty drawing
– Dysnomia
• Difficulty naming objects
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Tremor
Symmetrical increase or decrease in reflexes
Autonomic hyperactivity
Predisposing
Factors
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Advanced age
(over 60)
 Drug dependence
 Preexisting Brain
injury
Differential
Diagnosis
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Schizophrenia
 Dementia
 Psychotic
disorders
 Factitious disorder
with psychological
symptoms
Therapeutic Interventions &
Treatment
Identify and treat causative factors
 Recognize emergency situations
 Treat behavioral or psychiatric
symptoms
 Environmental treatments
 Education of support system
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Amestic Disorders
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Memory impairment
– absence of other significant cognitive
impairments
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Disturbance in memory
– due to direct physiological effects of GMC
– persisting effects of substance
• can be abuse
– medication
– toxin exposure
Amnesic Disorders
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Rare to last more than few months
Amnesia
– cannot learn new material
– Cannot recall recent events although maybe remote past
– Know self & name but not where at or what
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Some confabulation to fill gaps
Unaware of memory deficits/denial
May acknowledge but appear unconcerned
Age & onset varies
Common to head injury
Evidence memory disturbance – consequence of
medical condition or substance use
Causes
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Not part of delirium or dementia or intoxication or
withdrawal
Chronic heavy alcohol use
Stroke
Brain tumors
Repeated or severe hypoglycemia
– in poorly controlled diabetes
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Current or recent use of substance
Damage to certain brain structures
– caused by surgery, insufficient oxygen, cutoff of blood
flow
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Infection
Treatment
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Psychiatric interview and
assessment can reveal extent
of memory loss
 Medial focus is treating
underlying cause