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Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline...

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Delirium & Dementia Nicholas J. Silvestri, MD
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Page 1: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Delirium&Dementia

NicholasJ.Silvestri,MD

Page 2: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Outline

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

Page 3: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Deliriumvs.Dementia

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

– Speechdisorganized– Usuallyreversible

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

– Speechlargelyintact– Usuallyirreversible

Page 4: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

UnderlyingPathways

Page 5: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

UnderlyingPathways

Page 6: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Encephalopathy

• Theinabilitytomaintainacoherentstreamofthoughtoraction

• Inattentive• Easilydistractible

Page 7: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

CausesofEncephalopathy

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

Page 8: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

MetabolicEncephalopathy

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

Page 9: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

InfectiousEncephalopathy

• Encephalitisvs.meningitis• Importanttoconsideriffeverpresent• Quickinstitutionoftherapynecessary• LowthresholdforLP

Page 10: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Stupor,Obtundation,andOtherBadWords

Page 11: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Coma

• Patientisunconscious• Nopurposefulresponsetotheenvironment– Spontaneous,tocommand,tonoxiousstimuli

• Cannotbearoused• Eyesclosed

Page 12: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

EtiologyofComa

• Medical– Diffusehypoxia/ischemia– Dysglycemia– Organfailureordysfunction

– Intoxications– Severeelectrolyteimbalances

– CNSinfections

• Surgical– Intracranialhemorrhage– Intracerebralmasses– Largestrokes– Traumaticbraininjury

Page 13: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

BrainDeath

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

Page 14: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

ExaminationinComa

• Assessforarousal• Examineeyes– Pupillaryresponse,cornealresponse,oculocephalic response

• Evaluateforgagreflex• Evaluateforresponsetonoxiousstimuli• Evaluatemotorresponsetonoxiousstimuli

Page 15: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Dementia

• Progressivedisorderofcognitivefunctioninvolvingmemoryandatleastoneothercognitivedomain

Page 16: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

CausesofDementia

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

Page 17: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Alzheimer’sDisease

• Mostcommoncauseofdementia• Prevalenceincreaseswithage• Usuallysporadic(95%ofcases)

Page 18: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Pathogenesis

• β-amyloid- formsneuritic plaques-extracellulardeposits

• Neurofibrillarytangles- intracellulardepositscontaininghyperphosphorylated τ proteinandubiquitin

• Cholinergicdeficiency– DegenerationofnucleusbasalisofMeynert andseptal-hippocampaltract

Page 19: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Pathology

Page 20: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

MRIinAlzheimer’sDisease

Page 21: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

ClinicalManifestations

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

• Late– Disinhibition– Psychiatricmanifestations– Eventuallyakinetic mutism

Page 22: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Treatment

• Acetylcholinesteraseinhibitors– Donepezil,rivastigmine,galantamine

• NMDA-glutamatereceptorantagonist–Memantine

• Symptomatictreatment– Forpsychosis,depression,etc.

• Supportivecare

Page 23: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

FrontotemporalDementia

• EarlieronsetthanAlzheimer’s• Moreprominentbehavioralthancognitivedysfunctionatonset

• Preferentialatrophyoffrontalandanteriortemporallobes

• Duetoabnormalaccumulationofτ protein• Notreatment

Page 24: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

FrontotemporalDementia

Page 25: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Lewy BodyDementia

• Secondmostcommoncauseofdementia• CausedbypresenceofLewy bodiesthroughoutthecortexmadeupofα-synuclein

Page 26: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

ClinicalFeatures

• Dementia–MemorylessprominentlyinvolvedthanAlzheimer

• Parkinsonism– Tremor,bradykinesia,rigidity,gaitdysfunction

• Fluctuationofcognition• Visualhallucinations

Page 27: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

VascularDementia

• Thirdmostcommoncauseofdementia• Relationshipbetweencerebrovasculardiseaseanddementiaispoorlycharacterized

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

Page 28: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

VascularDementia

Page 29: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

VascularDementia

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

Page 30: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

OtherCausesofDementia

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

• Associatedwithotherdisease– Parkinson’sdisease– AIDS

Page 31: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

NeurologicalManifestationsofHIV

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

Page 32: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Neuro-cognitiveSymptoms

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

Page 33: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

MRIFindings

Page 34: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

AIDSDementiaComplex

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

Page 35: Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline •Delirium vs. Dementia ... –For psychosis, depression, etc. •Supportive care.

Questions?


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