Cognitive disorders. Dr S. Mashaphu Department of Psychiatry

Transcription

1 Cognitive disorders Dr S. Mashaphu Department of Psychiatry

2 Delirium Syndrome characterised by: Disturbance of consciousness Impaired attention Change in cognition Develops over hours-days Fluctuates during the course of the day.

3 Delirium Common among medical patients 10-15% affected Post-surgical patients esp. the elderly ICU patients Patients with a pre-existing dementia Patients with fractures Patients with systemic infections Drug withdrawal/intoxication

4 Delirium Clinical findings: Rapid onset Global cognitive impairment Disorientation Confusion Disturbance in consciousness Difficulty focussing, sustaining or shifting attention

5 Delirium Clinical features cont Patient may appear normal at times May develop hallucinations Symptoms get worse at night Agitation and aggression common

6 Delirium Evaluation History Physical examination Full neurological examination Laboratory investigations Biochemical profile Radiological investigations CT brain EEG

7 Delirium Differential diagnosis Mania Schizophrenia Dementia Psychotic disorder due to GMC Substance intoxication

8 Delirium Clinical management Correct underlying medical/surgical condition General measures Constant observation Frequent reassurance May need to restrain Minimise external stimulation

9 Delirium Clinical management Psychopharmacology Lorazepam 2-4mg hourly Haloperidol (low dose) 0.5mg b.d May use Risperidone 0.5mg b.d Avoid Chlorpromazine due to anticholinergic properties (worsen/prolong delirium)

10 Delirium Course and prognosis Symptoms persist for as long as underlying condition is present Generally lasts less than a week After removing causative factor symptoms improve within 7 days. Associated with a high mortality rate.

11 Syndrome characterised by: Impairment of cognition and memory Decline in social and occupational functioning No disturbance in consciousness Personality changes Some neurological deficits

12 Cognitive impairment includes: Aphasia (language disturbance) Amnesia Apraxia (inability to carry out motor activities) Agnosia (failure to recognise objects despite intact sensory function)

13 Background information Most dementias are irreversible 15% reversible Uncommon under age 65 Dementia of the Alzheimer s type is the commonest Vascular dementia is the second commonest HIV dementia becoming more prevalent

14 Causes: Vascular e.g. multiple infarcts Metabolic e.g. encephalopathy Nutritional e.g. thiamine deficiency Endocrine e.g. hypothyroidism Toxicity e.g. mercury Infections e.g encephalitis, HIV Tumours e.g meningiomas Normal pressure hydrocephalus

15 Clinical features: Depends on the underlying cause. Insidious vs sudden onset Personality change depends on lobe involved Loss of intellectual skills Memory impairment, long term memory affected last

16 Clinical feature: Depends on the underlying cause. Loss of social skills Motor symptoms Psychotic symptoms may develop Impaired judgement Language impairment

17 Diagnosis History and collateral information Physical examination Mental state examination Mini mental state examination Laboratory investigations (medical work-up) Radiological investigations EEG Neuropsychological testing

18 Types: Alzheimer s dementia Most common 50-60% of dementias Symptoms begin gradually and worsen progressively May develop delusions and hallucinations Cortical atrophy and enlarged cerebral ventricles on CT

19 Other types Vascular dementia Pick s disease Huntington s disease Creutzfeldt-Jakob disease HIV dementia Head trauma related dementia Substance induced persisting dementia

20 Clinical management Behavioural interventions Reality orientation Day care centres Group therapy Supportive therapy Support for family and care-giver

21 Clinical management Antipsychotics low dose Haloperidol, Risperidone Benzodiazepines e.g Clonazepam, Lorazepam Anticonvulsants e.g. Carbamazepine, Sodium Valproate Cognitive enhancers e.g Tacrine, Aricept, Vitamin E Antidepressants e.g. Citalopram

22 Differential diagnosis Delirium Psychotic disorder due to general medical condition Schizophrenia Normal aging Factitious disorder Depression with pseudodementia

23 Course and prognosis Gradual deterioration over 5-10years Mean survival is 8 years Prognosis will also depend on the underlying cause Current treatments improve quality of life Some drugs are able to halt the dementing process Reversibility remains debatable.

24 The end Thank you.