Delirium&Dementia

NicholasJ.Silvestri,MD

Outline

• Deliriumvs.Dementia• Neuralpathwaysrelatingtoconsciousness• Encephalopathy• “Stupor”• Coma• Dementia

Deliriumvs.Dementia

• Delirium– Abruptonset– Lastshours-days– Reducedattention– Fluctuatingconsciousness

– Speechdisorganized– Usuallyreversible

• Dementia– Insidiousonset– Lastsmonths-years– Normalattention– Consciousnessintact

– Speechlargelyintact– Usuallyirreversible

UnderlyingPathways

UnderlyingPathways

Encephalopathy

• Theinabilitytomaintainacoherentstreamofthoughtoraction

• Inattentive• Easilydistractible

CausesofEncephalopathy

• Toxic-Metabolic• Infectious• Vascular(e.g.hypertensiveencephalopathy)• Traumatic(e.g.concussion,hemorrhage)• Epileptic(e.g.post-ictalstate)

MetabolicEncephalopathy

• Drugs(EtOH,sedatives,narcotics)• Endocrine(hypo- orhyper- thyroid,glycemia)• Electrolyte(hypernatremia,hypercalcemia)• Nutritional(B1orB12deficiency)• Organsystemfailure(renal,hepatic)

InfectiousEncephalopathy

• Encephalitisvs.meningitis• Importanttoconsideriffeverpresent• Quickinstitutionoftherapynecessary• LowthresholdforLP

Stupor,Obtundation,andOtherBadWords

Coma

• Patientisunconscious• Nopurposefulresponsetotheenvironment– Spontaneous,tocommand,tonoxiousstimuli

• Cannotbearoused• Eyesclosed

EtiologyofComa

• Medical– Diffusehypoxia/ischemia– Dysglycemia– Organfailureordysfunction

– Intoxications– Severeelectrolyteimbalances

– CNSinfections

• Surgical– Intracranialhemorrhage– Intracerebralmasses– Largestrokes– Traumaticbraininjury

BrainDeath

• Irreversiblecessationofallbrainfunction• SynonymouswithdeathinNYS• Causeofcomamustbeknown• Otherconfoundersmustberuled-out– e.g.drugintoxication,hypothermia,etc.

ExaminationinComa

• Assessforarousal• Examineeyes– Pupillaryresponse,cornealresponse,oculocephalic response

• Evaluateforgagreflex• Evaluateforresponsetonoxiousstimuli• Evaluatemotorresponsetonoxiousstimuli

Dementia

• Progressivedisorderofcognitivefunctioninvolvingmemoryandatleastoneothercognitivedomain

CausesofDementia

• Alzheimer’sdisease• Frontotemporaldementia• Lewy Bodydementia• Vasculardementia• Othercauses

Alzheimer’sDisease

• Mostcommoncauseofdementia• Prevalenceincreaseswithage• Usuallysporadic(95%ofcases)

Pathogenesis

• β-amyloid- formsneuritic plaques-extracellulardeposits

• Neurofibrillarytangles- intracellulardepositscontaininghyperphosphorylated τ proteinandubiquitin

• Cholinergicdeficiency– DegenerationofnucleusbasalisofMeynert andseptal-hippocampaltract

Pathology

MRIinAlzheimer’sDisease

ClinicalManifestations

• Early– Recentmemorydifficulty– Anomia(word-findingdifficulty)– Visuospatialdysfunction

• Late– Disinhibition– Psychiatricmanifestations– Eventuallyakinetic mutism

Treatment

• Acetylcholinesteraseinhibitors– Donepezil,rivastigmine,galantamine

• NMDA-glutamatereceptorantagonist–Memantine

• Symptomatictreatment– Forpsychosis,depression,etc.

• Supportivecare

FrontotemporalDementia

• EarlieronsetthanAlzheimer’s• Moreprominentbehavioralthancognitivedysfunctionatonset

• Preferentialatrophyoffrontalandanteriortemporallobes

• Duetoabnormalaccumulationofτ protein• Notreatment

FrontotemporalDementia

Lewy BodyDementia

• Secondmostcommoncauseofdementia• CausedbypresenceofLewy bodiesthroughoutthecortexmadeupofα-synuclein

ClinicalFeatures

• Dementia–MemorylessprominentlyinvolvedthanAlzheimer

• Parkinsonism– Tremor,bradykinesia,rigidity,gaitdysfunction

• Fluctuationofcognition• Visualhallucinations

VascularDementia

• Thirdmostcommoncauseofdementia• Relationshipbetweencerebrovasculardiseaseanddementiaispoorlycharacterized

• Pathogenesis– 1.Multiplestrategicinfarcts– 2.Confluentwhitematterdisease– 3.Both

VascularDementia

VascularDementia

• “Step-wiseprogression”• Treatmentissupportive– Largelyaimedattreatingmodifiablevascularriskfactors(bloodpressure,lipids,diabetes)

OtherCausesofDementia

• Potentiallyreversiblecauses– Hyper- orhypothyroidism– normalpressurehydrocephalus– B12deficiency– neurosyphilis

• Associatedwithotherdisease– Parkinson’sdisease– AIDS

NeurologicalManifestationsofHIV

• Seeninupto70%ofpatientswithHIV/AIDS• Twomajorpathophysiologicmechanisms:– DirecteffectsofHIVonnervoussystem– Opportunisticinfections

Neuro-cognitiveSymptoms

• Subcorticaldementia• Difficultieswithattentionandconcentration• Slowprocessingspeed• Mildshorttermmemorydysfunction• Declineinpsychomotorfunction– Finehandmovements,gaitincooordination

MRIFindings

AIDSDementiaComplex

• a.k.a.HIVencephalopathy• Occurslaterindiseasecourse• Moreseverecognitiveandbehavioraldeficits• CanseewidespreadwhitematterdiseaseandatrophyonMRI

Questions?