Cognitive DisordersCognitive Disorders

Delirium

Dementia

Amnestic Disoders

CharacteristicsCharacteristics•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 ProcessDiagnostic Process

Symptoms consistent with recognized cognitive impairment

Search for underlying physiological cause

Team based assessment

Recording ProceduresRecording 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

With dementia: Note if there is a behavioral disturbance

SuperimposedSuperimposed

If in progression of existing dementia– delirium develops

•subtype is noted

An example– Dementia, Alzheimer’s type, late

onset, with Delirium•Dementia diagnosed 1st, the delirium

arrived

DifferencesDifferences

Delirium– Disturbance in consciousness accompanied

by widespread brain dysfunctionDementia

– Distinguished by impairment in memory• sort or long term• recent & remote

– Also impairment of 1 other brain functionBoth:

Exhibit signs & symbols of global brain dysfunction

DementiaDementia

Can be referred to as senility, gradual deterioration of intellectual abilities to where it impairs social and occupational functioning

Multiple cognitive deficits which are skill oriented, indicate global brain dysfunction

Easier to diagnose than delirium

Clients may present with cognitive disturbances

Dementia Dementia

May be caused by:– nonpsychiatric medical condition– a substance or – mixture

Terms– Aphasia – inability to understand or

produce language– Apraxia – loss of motor skill– Agnosia – problems with visual &

spatial

Causes of DementiaCauses of Dementia Over 70 possible causes Alzheimer's

– diagnosed only by ruling other things out Primary dementias

– produced directly by brain impairment Secondary dementias

– caused by diseases not attacking brain directly• Depression• Hormonal imbalances• Drugs• Arteriosclerosis• Pneumonia• HIV• etc

What Does Dementia Look Like?What Does Dementia Look Like? 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 - DementiaDifferential Diagnosis - Dementia

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 DepressionDementia versus DepressionBoth may have poor judgment, somatic complaints, & psychotic Both may have poor judgment, somatic complaints, & psychotic behaviorsbehaviors

In Dementia– Memory deficits– Perseveration – Affect is

“suggestible” – Affect is

inconsistent

In Depression– Difficulty in

concentration– Difficulty learning

new information– Affect is not

influenced by others

– No cognitive disturbances

Dementia: Treatment PossibilitiesDementia: Treatment Possibilities

Depends on type of dementia diagnosed

No treatment for biological componentFind cause and attempt to treat it firstFocus on client management and

environmentSome types of medication may helpCounseling for client and support

group

DeliriumDelirium Disturbance of consciousness & change

in cognition Decline from higher functioning Impairment in occupational or social

functioning Difficulties with assessment

– 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 DeliriumCauses of Delirium

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

Seizure or traumatic brain injury Multiple etiologies

What does delirium look like?What does delirium look like? Cannot concentrate

– Difficulty maintaining or shifting attention Manifest disorganized thinking Misinterpretations of environment

– 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)

FOR MORE INFO...

http://www.mentalhealth

Associated FeaturesAssociated Features

Emotional disturbances Neurological signs

– Dysgraphia• Difficulty writing

– Constructional apraxia• Difficulty drawing

– Dysnomia• Difficulty naming objects

Tremor Symmetrical increase or decrease in reflexes Autonomic hyperactivity

PredisposingPredisposing Differential Differential FactorsFactors DiagnosisDiagnosis Advanced age

(over 60) Drug dependence Preexisting Brain

injury

Schizophrenia Dementia Psychotic

disorders Factitious disorder

with psychological symptoms

Therapeutic Interventions & Therapeutic Interventions & TreatmentTreatment

Identify and treat causative factorsRecognize emergency situationsTreat behavioral or psychiatric

symptomsEnvironmental treatmentsEducation of support system

Amestic DisordersAmestic Disorders

Memory impairment– absence of other significant cognitive

impairments

Disturbance in memory– due to direct physiological effects of GMC– persisting effects of substance

• can be abuse

– medication– toxin exposure

Amnesic DisordersAmnesic Disorders

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

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

CausesCauses

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 Current or recent use of substance Damage to certain brain structures

– caused by surgery, insufficient oxygen, cutoff of blood flow

Infection

TreatmentTreatment

Psychiatric interview and assessment can reveal extent of memory loss

Medial focus is treating underlying cause