Cognitive Impairment. LPT Gondar Mental Health Group.

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1 Cognitive Impairment LPT Gondar Mental Health Group

2 Areas to be covered Causes of cognitive impairment Delirium Definition and causes Clinical features Management principles Dementia Common causes and epidemiology Clinical features and assessment Treatment and other management issues Neuro-psychiatric manifestations of HIV

3 Causes of cognitive impairment

4 Causes of cognitive impairment Delirium Dementia Amnestic syndrome Primary psychotic illness Depression Learning disability Brain damage

5 Delirium Is also called acute confusional state The underlying cause is a physical disorder

6 Delirium; symptoms Global impairment of cognition; disturbances of attention and conscious level; abnormal psychomotor behaviour and affect; disturbed sleep-wake cycle Onset is usually acute (hours/days) All symptoms fluctuate during daytime and are typically worst at night Hallucinations and illusions; usually visual modality Patients may be predominantly hypo- or hyperactive or switch between the two states

7 Delirium - impaired consciousness Typically, like other features, will fluctuate Continuum from full alertness through to unconsciousness Earliest stage = clouding of consciousness, characterised by attentional deficits

8 Delirium - perceptual disturbance Usually in the visual modality Illusions are common as well

9 Causes of delirium Medication Metabolic Infection CVS CNS Other 5 0 Rudberg 1997 (n=63) George 1997 (n=217)

10 Drug induced delirium Psychotropic drugs Antidepressants Antipsychotics Benzodiazepines Antiparkinsonian drugs Anticholinergic drugs Opiates Diuretics (recreational drug intoxication and withdrawl)

11 Outcome of delirium Just because delirium is a transient mental disorder, it does not follow that all patients get better Prognosis of acutely ill patients is poorer in the presence of delirium: Increased mortality at 1 year (OR 2.3) Institutionalisation by 1 year (OR 4.5) Readmission within 1 year (OR 2.1)

12 Diagnosis of delirium Look for the clinical features especially fluctuating symptoms Assess cognitive function Identify the underlying physical illness

13 Delirium - management Treatment of the underlying condition General supportive measures e.g. Maintaining hydration and nutrition Attention to physical and human environment Control of distressing physical symptoms Symptomatic treatment of disturbed behaviour, if unavoidable Low dose Haloperidol can help the symptoms of delirium

14 Diagnostic guidelines - dementia Decline in both memory and thinking. Impaired personal ADLs Clear consciousness Illusions and hallucinations Above syndrome present for >= 6 months Changes in behaviour and personality

15 Why is dementia an important It is common mental health issue? It does not confer a static disability i.e. it is usually progressive It is very stressful for carers and the patient s family Those who are most dependent and vulnerable often have the least awareness of their disabilities

16 The common causes of dementia Alzheimer s disease(ad) c.60% Vascular dementia (VaD) - multi-infarct disease small vessel disease 15% Lewy body dementia (DLB) c.10-15% Other - including... Other neurodegenerative disease; CNS neoplasia, toxicity, inflammatory disease and infections; vitamin deficiency states; hypothyroidism etc etc

17 Pathology of Alzheimer's Disease Shrunken brain with widened sulci and enlarged ventricles Neuronal cell loss Plaques with a core of amyloid Neurofibrillary tangles

18 % Dementia epidemiology Prevalence and incidence is very highly agedependent but fairly similar in different countries Cross sectional prevalence: all-cause dementia Age - years

19 Presentation of dementia - early features With AD and several other dementias, circumscribed memory disorder may be the earliest feature Some level of insight and awareness may be present

20 Presentation of dementia - middle-stage features More pervasive and severe memory disorder, often with confabulation Disturbance of language and other cortical cognitive functions Alterations in personality, affect and behaviour Other non-cognitive features e.g. psychotic symptoms

21 Presentation of dementia - late features Profound impairments of memory, attention and other cognitive functions Language deficits may have become very pronounced - dysphasia Major behavioural abnormalities (+ve and -ve) Neurological disturbance and physical frailty

22 What is the difference between Alzheimer's dementia and delirium?

23 Assessment I - establishing the presence of dementia Two main requirements: Systematic cognitive assessment Informant history - onset and course of the problem

24 Assessment II - establishing underlying diagnoses Full mental state examination Physical examination Simple physical investigations e.g. CXR, ECG, blood tests Complex physical investigations brain imaging

25 The changing role of complex MRI now investigation of choice in all cases subject to availability and patient-tolerance Much greater utility for contributing to diagnosis for the common dementias investigations

26 General principles of management of dementia Traditionally: Symptomatic treatments and interventions for the patient Support for carer Now: Disease-specific drug treatments, which in turn may demand more complex diagnostic assessments

27 Vascular dementia More abrupt onset History of a stroke Fluctuating course Stepwise deterioration Neurological symptoms and signs Can look like delirium

28 Dementia with Lewy bodies Related to Parkinson s disease Fluctuating confusion Visual hallucinations Auditory hallucinations Delusions Parkinson s symptoms Can look like delirium Anti dementia drugs can help

29 Amnestic syndrome Immediate recall is normal Delayed recall is severely impaired Clear consciousness Long term memory and general cognitions relatively preserved Thiamine deficiency (Also related to HI and CO intoxication)

30

31 Primary psychiatric illnesses Depression Schizophrenia

32 Psychiatry and HIV Psychological consequences Neuropsychiatric disorders

33 Psychological consequences Adjustment disorder Depression Anxiety Suicide and deliberate self harm

34 Neuro-psychiatric consequences Primary HIV infection of the brain Opportunistic infections HIV associated infections (AIDS dementia complex) HIV encephalopathy Subacute encephalitis Neoplasm of CNS

35 Primary infection of the brain 10% neurological symptoms as presenting complain 30-60% brain involvement Focal neurological symptoms as well as symptoms of delirium Histological: encephalitis, myelopathy, vasculitis and HIV leuco-encephalitis

36 Opportunistic infections Viral Fungal Parasitic Causing symptoms of delirium

37 AIDS dementia complex 8-40% in the latter stages Sometimes an abrupt onset, sometimes insidious Cognitive impairment Motor deficits Behaviour changes Psychomotor slowing

38 Causes of cognitive impairment Delirium Dementia Amnestic syndrome Primary psychotic illness Depression Learning disability Brain damage

39 Any questions?

40 Provided by The Leicester Gondar Link Collaborative Teaching Project This work is licensed under a Creative Commons Attribution-NonCommercial- NoDerivs 3.0 Unported License.

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