4.

COGNITIVE DISORDERS
DSM-IV classifes three groups of isorers!
Deliriu"
De"e#tia
$"#estic isorers
The pri"ar% co""o# feature to all the isorers is a# i"pair"e#t i#
cog#itio#
& E.g.' "e"or%' la#guage' or atte#tio#'()
4.*. Deliriu"
Deliriu" is a# acute' re+ersi,le orga#ic co#itio# -ith "ultiple
etiologies.
The "a.or causes of eliriu"!-
CNS isease- e.g.' epileps%
S%ste"ic isease- e.g.' cariac failure
I#to/icatio# or -ithra-al fro" phar"acological or to/ic age#ts
0he# e+aluati#g a elirious patie#t' assu"e that a#% rug the
patie#t has ,ee# ta1e# "a% ,e causati+el% rele+a#t to the eliriu".
The "a.or #eurotra#s"itter h%pothesi2e to ,e i#+ol+e i#- is
acet%lcholi#e' a# the "a.or a#ato"ical area is reticular for"atio#.
Se+eral t%pes of stuies ha+e reporte that a +ariet% of eliriu"-
i#uci#g factors resulti#g i# ecrease acet%lcholi#e acti+it% i# the
,rai#.
O#e of the "ost co""o# causes of eliriu" is to/icit% fro" too
"a#% prescri,e "eicatio#s that ha+e a#ticholi#ergics acti+it%.
Trau"a 3 hea i#.ur%' post-operati+e states
I#fectio# 3 s%ste"ic i#fectio#s' septice"ia' i#tracra#ial i#fectio#s
such as "e#i#gitis a# e#cephalitis
Meta,olic causes 3 ure"ia' hepatic failure' co#gesti+e cariac
failure' -ater a# electrol%te i",ala#ces' h%po/ia etc(
E#ocri#e causes 3 h%pogl%ce"ia' ia,etic preco"a
Vascular causes 3 circulator% istur,a#ces
Neoplasms 3 pri"ar% a# seco#ar% #eoplas"s of the ,rai#
Others 3 +ita"i# efcie#c% &4*' 4*5') se#sor% epri+atio#(
Cli#ical 6eatures
The 1e% feature of eliriu" is a# i"pair"e#t of co#scious#ess.
7Reuce clarit% of a-are#ess of the e#+iro#"e#t'8 -ith reuce
a,ilit% to focus' sustai#' or shift atte#tio#.
Co""o#l%' the i"pair"e#t of co#scious#ess a# the i#a,ilit% to
atte# 9uctuate o+er the course of a a%: relati+el% luci perio is
etecte at a% ti"e.
Orie#tatio# to ti"e' place' a# perso# shoul ,e teste.
Orie#tatio# to ti"e is co""o#l% lost' e+e# i# "il case.
Orie#tatio# to place a# the a,ilit% to recog#i2e other perso#s- e.g.'
ph%sicia#' fa"il% "e",ers "a% ,e i"paire i# se+ere cases
$ elirious patie#t rarel% loses orie#tatio# to self.
;atie#ts -ith eliriu" ofte# ha+e a,#or"alities i# la#guage.
The a,#or"alities "a% i#clue ru",li#g' irrele+a#t' or i#cohere#t
speech' a# a# i"paire a,ilit% to co"prehe# speech.
Other cog#iti+e fu#ctio#s that "a% ,e i"paire i# a elirious
patie#t i#clue "e"or% a# ge#erali2e cog#iti+e fu#ctio#s.
;erceptual istur,a#ces' i# the for" of illusio#s a#
halluci#atio#s' ,oth +isual a# auitor%' are pro"i#e#t.
Mar1i#gs o# the ,e sheet or o# the -all are "ista1e# for cra-li#g
i#sects' -hich the patie#t tries to pic1 up a# thro- a-a%.
4ecause of auitor% halluci#atio#s to -hich the patie#t "a% ,e
respo#i#g' he oes #ot repl% to the e/a"i#er<s =uestio#s
;atie#ts -ith eliriu" ofte# ha+e a,#or"alities i# the
regulatio# of "oo.
The "ost co""o# s%"pto"s are a#ger' rage' a# u#-arra#te
fear.
Other a,#or"alities of "oo are apath%' epressio#' a# euphoria.
So"e patie#ts rapil% alter#ate a"o#g those e"otio#s -ithi# the
course of a a%.
The sleep of elirious patie#ts is characteristicall% istur,e.
;atie#ts are ofte# ro-s% uri#g the a% a# ca# ,e fou# #appi#g
i# their ,es or i# the a% roo"s.
The sleep of the elirious patie#t is al-a%s short a# frag"e#te.
;atie#ts so"eti"es ha+e a# e/acer,atio# of elirious s%"pto"s .ust
a,out ,eti"e' a cli#ical situatio# -iel% 1#o-# as sundowning.
Occasio#all%' the #ight"ares a# the istur,i#g rea"s of elirious
patie#ts co#ti#ue i#to -a1eful#ess as halluci#ator% e/perie#ces.
I#sight a# .ug"e#t are grossl% i"paire.
I#+estigatio#s
Deliriu" is a "eical e"erge#c% a# i#+estigatio#s to etect the
u#erl%i#g patholog% shoul ,e carrie out -ithout ela%.
Thoroughl% ta1e# histor%' particularl% relate to "eicatio#s a#
su,sta#ce use is #ecessar%.
The "e#tal status e/a"i#atio# shoul focus o# the cog#iti+e
fu#ctio#i#g of the patie#t.
$ #eurological e/a"i#atio# "a% gi+e relia,le cues.
>a,. tests i#clue a full or a co"plete hae"atogra" a# uri#e
a#al%sis' seru" electrol%tes' a# >6T.
CS6' EEG' if +alua,le a# -ill sho- cha#ges i# rh%th" a# slo-i#g.
TRE$TMENT
?ospitali2atio#' prefera,l% i# IC@ is i#icate a# treat"e#t shoul
,e irecte at the u#erl%i#g cause.
Meta,olic a,#or"alities are correcte a# h%ratio# a# #utritio#
care for.
6or patie#ts -ho are at ris1 of e+elopi#g sei2ures' a#tico#+ulsa#t is
#ecessar%.
;atie#t shoul ,e #urse i# a# e#+iro#"e#t -ith opti"u" se#sor%
sti"uli.
-Too "uch or too little se#sor% sti"ulatio# "a% ,e har"ful.
The roo" shoul ,e =uiet a# ae=uatel% lighte e/cept for those
se#sor% epri+atio#
6re=ue#t cha#ge of #ursi#g perso##el is to ,e a+oie so that the
patie#t is fa"iliar -ith the atte#i#g staA.
Relati+es shoul ,e e#courage to +isit the patie#t fre=ue#tl% for
the sa"e reaso#.
Soft ph%sical restrai#s "a% ,e #eee i# case of se+ere restless#ess
a# e/cite"e#t.
The t-o "a.or s%"pto"s of eliriu" that "a% re=uire
phar"acological treat"e#t are ps%chosis a# i#so"#ia.
The rug of choice for ps%chosis is haloperiol &?alol)' a ,ut%rophe#o#e
a#tips%chotic rug.
Depe#i#g o# the patie#t<s age' -eight' a# ph%sical co#itio#' the i#itial
ose "a% ra#ge fro" 5-*B "g IM' repeate i# a# hour if the patie#t
re"ai#s agitate. $s soo# as the patie#t is cal"' oral "eicatio# i# li=ui
co#ce#trate or ta,let for" shoul ,egi#. T-o ail% oral oses shoul
suCce' -ith t-o thirs of the rug ,ei#g gi+e# at ,eti"e. To achie+e the
sa"e therapeutic eAect' the oral ose shoul ,e a,out *.D ti"es higher
tha# the pare#teral ose.
The eAecti+e total ail% osage of haloperiol "a% ra#ge fro" D-EB "g for
the "a.orit% of the elirious patie#ts.
;he#othia2i#es &e.g. chlorpro"a2i#e) shoul ,e a+oie i# elirious
patie#ts' ,ecause of their a#ti-choli#ergic acti+it%.
I#so"#ia is ,est treate -ith ,e#2oia2epi#e -ith short half-li+es. E.g.
lora2epa"
4e#2oia2epi#es -ith lo#g half-li+es a# ,ar,iturates shoul ,e a+oie
u#less the% are ,ei#g use as part of the treat"e#t for the u#erl%i#g
isorer- e.g.' alcohol -ithra-al.
4.5. DEMENTI$
De"e#tia- is a progressi+e' generalized impairment of intellectual
functions a# memory
-ithout i"pair"e#t of co#scious#ess.
De"e#tias are chro#ic
Etiolog%
De"e#tia has "a#% causes!
De"e#tia of $l2hei"er<s t%pe a# +ascular e"e#tia together represe#t
FDG of all cases.
Other causes of e"e#tia are!
Trau"a 3 hea i#.ur%' repeate hea i#.uries as i# ,o/ers &pu#ch-
ru#1 s%#ro"e)
I#fectio#s 3 e#cephalitis' $DIS e"e#tia co"ple/
Vascular 3 si#gle or "ultiple i#farcts' su,ural hae"ato"a
Meta,olic 3 ure"ia' hepatic failure' h%percalcae"ia
E#ocri#al - h%poth%roiis"
Neoplas"s 3 pri"ar% a# seco#ar% &"etastatic) cere,ral tu"ors
Dege#erati+e 3 $l2hei"er<s isease' ;ic1<s isease' ?u#ti#gto#<s
isease' ;ar1i#so#<s isease
Others 3 Epileps%' a#o/ia' #or"al pressure h%rocephalus' +ita"i#
&4*5) efcie#cies' alcohol' "ultiple sclerosis.
The "a.or efects i# e"e#tia i#+ol+e!
Orie#tatio#
Me"or%
;erceptio#
I#tellectual fu#ctio#i#g
Reaso#i#g
$ll those fu#ctio#s ,eco"e progressi+el% aAecte as the isease process
a+a#ces.
Me"or% i"pair"e#t is t%picall% a# earl% a# pro"i#e#t feature i#
e"e#tia' especiall% i# e"e#tias i#+ol+i#g the corte/' such as
e"e#tia of the $l2hei"er<s t%pe.
Earl% i# the course of e"e#tia' "e"or% i"pair"e#t is "il a# is usuall%
"ar1e for rece#t e+e#ts' such as forgetti#g telepho#e #u",ers'
co#+ersatio#s' a# e+e#ts of the a%.
$s the course of e"e#tia progresses' "e"or% i"pair"e#t ,eco"es
se+ere' a# o#l% the "ost highl% lear#e i#for"atio#- e.g.' place of ,irth is
retai#e.
$s "uch as "e"or% is i"porta#t for orie#tatio# to perso#' place'
a# ti"e' orie#tatio# ca# ,e progressi+el% aAecte uri#g the
course of a e"e#ti#g ill#ess.
e.g.' patie#ts -ith e"e#tia "a% forget ho- to get ,ac1 to their roo"s
after goi#g to the ,athroo".
No "atter ho- se+ere the isorie#tatio# see"s' the patie#t sho-s
#o i"pair"e#t i# the le+el of co#scious#ess.
De"e#ti#g processes that aAect the corte/' pri"aril% e"e#tia of
$l2hei"er<s t%pe a# +ascular e"e#tia' ca# aAect the patie#t<s
la#guage a,ilities.
$phasia is o#e of the iag#ostic criteria.
The la#guage iCcult% "a% ,e characteri2e ,% a +ague'
stereot%pe' i"precise' or circu"sta#tial locutio#.
The patie#t "a% also ha+e iCcult% i# #a"i#g o,.ects.
;re-e/isti#g perso#alit% traits "a% ,e acce#tuate uri#g the
e+elop"e#t of a e"e#tia.
De"e#te patie#ts -ho ha+e para#oi elusio#s are ge#erall%
hostile to fa"il% "e",ers a# careta1ers.
;atie#ts -ith fro#tal a# te"poral i#+ol+e"e#t are li1el% to ha+e
perso#alit% cha#ges a# "a% ,e irrita,le a# e/plosi+e
$# esti"ate 5B-EBG of e"e#te patie#ts' pri"aril% -ith e"e#tia
of the $l2hei"er<s t%pe' ha+e halluci#atio#s' a# EB-4BG of pts
ha+e elusio#s' pri"aril% of para#oi or persecutor% a#
u#s%ste"ati2e #ature. ;h%sical aggressio# a# other for"s of
+iole#ce are co""o# i# e"e#te patie#ts -ho ha+e ps%chotic
s%"pto"s
Treat"e#t
S%"pto"atic treat"e#t i#clues!
The "ai#te#a#ce of #utritious iet
;roper e/ercise
Recreatio#al a# acti+it% therapies
$tte#tio# to +isual a# auitor% pro,le"s
Treat"e#t of associate "eical pro,le"s- such as uri#ar% tract
i#fectio#s' ecu,itus ulcers' a# cariopul"o#ar% %sfu#ctio#.
;articular atte#tio# "ust ,e pro+ie to careta1ers a# fa"il%
"e",ers -ho eal -ith frustratio#' grief' a# ps%chological ,ur#out
as the% care for the patie#t o+er a lo#g perio.
0he# the iag#osis of +ascular e"e#tia is "ae' ris1 factors
co#tri,uti#g to cere,ro-+ascular isease shoul ,e ie#tife a#
therapeuticall% aresse.
Those factors i#clue!-
- ?%perte#sio#
- ?%perlipie"ia
- O,esit%
- Cariac isease
- Dia,etes a#
-alcohol epe#e#ce
;atie#ts -ho s"o1e shoul ,e e#courage to stop' si#ce s"o1i#g
cessatio# is associate -ith i"pro+e cere,ral perfusio# a#
cog#iti+e fu#ctio#i#g.
Curre#t $+aila,le phar"acologic Treat"e#ts
Short acti#g ,e#2oia2epi#e for i#so"#ia a# a#/iet%
$#tiepressa#t for epressio#
$#tips%chotic rugs for elusio#s a# halluci#atio#s
I# ge#eral rugs -ith high a#ticholi#ergics acti+it% shoul ,e
a+oie
E+e# if thioria2i#e ha+e high a#ticholi#ergic acti+it%' it is eAecti+e
i# co#trolli#g ,eha+ior i# e"e#te patie#ts -he# gi+e# i# lo-
osages.
Do#epe2il' Ri+astig"i#e' Gala#ta"i#e' a# Tacri#e are
choli#esterase i#hi,itors use to treat "il to "oerate cog#iti+e
i"pair"e#t i# $l2hei"er<s isease.
The% reuce the i#acti+atio# of the #eurotra#s"itter acet%lcholi#e
a# pote#tiate the choli#ergic #eurotra#s"itter' -hich i# tur#
prouces a "oest i"pro+e"e#t i# "e"or% a# goal irecte
thought.
4.E. $"#estic Disorers
$"#estic Disorers are characteri2e ,% se+ere "e"or%
i"pair"e#t for rece#t e+e#ts.
>o#g-ter" "e"or% is so"eti"es aAecte. I""eiate recall of
e+e#ts is #or"al' as are other cog#iti+e fu#ctio#s.
The patie#t is alert a# co#+ersatio# ca# ,e carrie out #or"all%.
>ear#i#g of #e- "aterial is grossl% aAecte.
Seco#ar% to the "e"or% i"pair"e#t there "a% ,e isorie#tatio#
of ti"e. Gaps i# "e"or% are flle ,% co#fa,ulatio#.
Etiolog%
The co""o#est cause i# cli#ical practice is alcohol a,use' a# is
cause ,% thia"i#e efcie#c%.
Gastric carci#o"a a# ietar% efcie#cies resulti#g i# thia"i#e
efcie#c% prouces a"#estic s%#ro"es.
Da"age to ie#cephalic a# "eial te"poral structures &"a"illar%
,oies' for#i/' hippoca"pus) as a result of surger% or trau"a'
a#o/ia' i#fractio#' i#fectio#s' CO poiso#i#g or #eoplas"s of thir
+e#tricle result i# a"#estic s%#ro"es.
Treat"e#t
The pri"ar% approach is to treat the u#erl%i#g cause of the
a"#estic isorer.
The a"i#istratio# of thia"i#e "a% pre+e#t the e+elop"e#t of
aitio#al a"#estic s%"pto"s' ,ut rarel% is the treat"e#t a,le to
re+erse se+ere a"#estic s%"pto"s' o#ce the% are prese#t.
0hile the patie#t is a"#estic' supporti+e pro"pts regari#g the
ate' the ti"e' a# the patie#t<s locatio# ca# ,e helpful a# ca#
reuce the patie#t<s a#/iet%.
$fter the resolutio# of the a"#estic episoe' supporti+e
ps%chotherap% "a% help patie#ts i#corporate the a"#estic
e/perie#ce i# to their li+es.
D. COGNITIVE DISORDERS
DSM-IV classifes three groups of isorers!
Deliriu"
De"e#tia
$"#estic isorers
The pri"ar% co""o# feature to all the isorers is a# i"pair"e#t i#
cog#itio#
& E.g.' "e"or%' la#guage' or atte#tio#'()
D.*. Deliriu"
Deliriu" is a# acute' re+ersi,le orga#ic co#itio# -ith "ultiple
etiologies.
The "a.or causes of eliriu"!-
CNS isease- e.g.' epileps%
S%ste"ic isease- e.g.' cariac failure
I#to/icatio# or -ithra-al fro" phar"acological or to/ic age#ts
0he# e+aluati#g a elirious patie#t' assu"e that a#% rug the
patie#t has ,ee# ta1e# "a% ,e causati+el% rele+a#t to the eliriu".
The "a.or #eurotra#s"itter h%pothesi2e to ,e i#+ol+e i#- is
acet%lcholi#e' a# the "a.or a#ato"ical area is reticular for"atio#.
Se+eral t%pes of stuies ha+e reporte that a +ariet% of eliriu"-
i#uci#g factors resulti#g i# ecrease acet%lcholi#e acti+it% i# the
,rai#.
O#e of the "ost co""o# causes of eliriu" is to/icit% fro" too
"a#% prescri,e "eicatio#s that ha+e a#ticholi#ergics acti+it%.
Trau"a 3 hea i#.ur%' post-operati+e states
I#fectio# 3 s%ste"ic i#fectio#s' septice"ia' i#tracra#ial i#fectio#s
such as "e#i#gitis a# e#cephalitis
Meta,olic causes 3 ure"ia' hepatic failure' co#gesti+e cariac
failure' -ater a# electrol%te i",ala#ces' h%po/ia etc(
E#ocri#e causes 3 h%pogl%ce"ia' ia,etic preco"a
Vascular causes 3 circulator% istur,a#ces
Neoplasms 3 pri"ar% a# seco#ar% #eoplas"s of the ,rai#
Others 3 +ita"i# efcie#c% &4*' 4*5') se#sor% epri+atio#(
Cli#ical 6eatures
The 1e% feature of eliriu" is a# i"pair"e#t of co#scious#ess.
7Reuce clarit% of a-are#ess of the e#+iro#"e#t'8 -ith reuce
a,ilit% to focus' sustai#' or shift atte#tio#.
Co""o#l%' the i"pair"e#t of co#scious#ess a# the i#a,ilit% to
atte# 9uctuate o+er the course of a a%: relati+el% luci perio is
etecte at a% ti"e.
Orie#tatio# to ti"e' place' a# perso# shoul ,e teste.
Orie#tatio# to ti"e is co""o#l% lost' e+e# i# "il case.
Orie#tatio# to place a# the a,ilit% to recog#i2e other perso#s- e.g.'
ph%sicia#' fa"il% "e",ers "a% ,e i"paire i# se+ere cases
$ elirious patie#t rarel% loses orie#tatio# to self.
;atie#ts -ith eliriu" ofte# ha+e a,#or"alities i# la#guage.
The a,#or"alities "a% i#clue ru",li#g' irrele+a#t' or i#cohere#t
speech' a# a# i"paire a,ilit% to co"prehe# speech.
Other cog#iti+e fu#ctio#s that "a% ,e i"paire i# a elirious
patie#t i#clue "e"or% a# ge#erali2e cog#iti+e fu#ctio#s.
;erceptual istur,a#ces' i# the for" of illusio#s a#
halluci#atio#s' ,oth +isual a# auitor%' are pro"i#e#t.
Mar1i#gs o# the ,e sheet or o# the -all are "ista1e# for cra-li#g
i#sects' -hich the patie#t tries to pic1 up a# thro- a-a%.
4ecause of auitor% halluci#atio#s to -hich the patie#t "a% ,e
respo#i#g' he oes #ot repl% to the e/a"i#er<s =uestio#s
;atie#ts -ith eliriu" ofte# ha+e a,#or"alities i# the
regulatio# of "oo.
The "ost co""o# s%"pto"s are a#ger' rage' a# u#-arra#te
fear.
Other a,#or"alities of "oo are apath%' epressio#' a# euphoria.
So"e patie#ts rapil% alter#ate a"o#g those e"otio#s -ithi# the
course of a a%.
The sleep of elirious patie#ts is characteristicall% istur,e.
;atie#ts are ofte# ro-s% uri#g the a% a# ca# ,e fou# #appi#g
i# their ,es or i# the a% roo"s.
The sleep of the elirious patie#t is al-a%s short a# frag"e#te.
;atie#ts so"eti"es ha+e a# e/acer,atio# of elirious s%"pto"s .ust
a,out ,eti"e' a cli#ical situatio# -iel% 1#o-# as sundowning.
Occasio#all%' the #ight"ares a# the istur,i#g rea"s of elirious
patie#ts co#ti#ue i#to -a1eful#ess as halluci#ator% e/perie#ces.
I#sight a# .ug"e#t are grossl% i"paire.
I#+estigatio#s
Deliriu" is a "eical e"erge#c% a# i#+estigatio#s to etect the
u#erl%i#g patholog% shoul ,e carrie out -ithout ela%.
Thoroughl% ta1e# histor%' particularl% relate to "eicatio#s a#
su,sta#ce use is #ecessar%.
The "e#tal status e/a"i#atio# shoul focus o# the cog#iti+e
fu#ctio#i#g of the patie#t.
$ #eurological e/a"i#atio# "a% gi+e relia,le cues.
>a,. tests i#clue a full or a co"plete hae"atogra" a# uri#e
a#al%sis' seru" electrol%tes' a# >6T.
CS6' EEG' if +alua,le a# -ill sho- cha#ges i# rh%th" a# slo-i#g.
TRE$TMENT
?ospitali2atio#' prefera,l% i# IC@ is i#icate a# treat"e#t shoul
,e irecte at the u#erl%i#g cause.
Meta,olic a,#or"alities are correcte a# h%ratio# a# #utritio#
care for.
6or patie#ts -ho are at ris1 of e+elopi#g sei2ures' a#tico#+ulsa#t is
#ecessar%.
;atie#t shoul ,e #urse i# a# e#+iro#"e#t -ith opti"u" se#sor%
sti"uli.
-Too "uch or too little se#sor% sti"ulatio# "a% ,e har"ful.
The roo" shoul ,e =uiet a# ae=uatel% lighte e/cept for those
se#sor% epri+atio#
6re=ue#t cha#ge of #ursi#g perso##el is to ,e a+oie so that the
patie#t is fa"iliar -ith the atte#i#g staA.
Relati+es shoul ,e e#courage to +isit the patie#t fre=ue#tl% for
the sa"e reaso#.
Soft ph%sical restrai#s "a% ,e #eee i# case of se+ere restless#ess
a# e/cite"e#t.
The t-o "a.or s%"pto"s of eliriu" that "a% re=uire
phar"acological treat"e#t are ps%chosis a# i#so"#ia.
The rug of choice for ps%chosis is haloperiol &?alol)' a ,ut%rophe#o#e
a#tips%chotic rug.
Depe#i#g o# the patie#t<s age' -eight' a# ph%sical co#itio#' the i#itial
ose "a% ra#ge fro" 5-*B "g IM' repeate i# a# hour if the patie#t
re"ai#s agitate. $s soo# as the patie#t is cal"' oral "eicatio# i# li=ui
co#ce#trate or ta,let for" shoul ,egi#. T-o ail% oral oses shoul
suCce' -ith t-o thirs of the rug ,ei#g gi+e# at ,eti"e. To achie+e the
sa"e therapeutic eAect' the oral ose shoul ,e a,out *.D ti"es higher
tha# the pare#teral ose.
The eAecti+e total ail% osage of haloperiol "a% ra#ge fro" D-EB "g for
the "a.orit% of the elirious patie#ts.
;he#othia2i#es &e.g. chlorpro"a2i#e) shoul ,e a+oie i# elirious
patie#ts' ,ecause of their a#ti-choli#ergic acti+it%.
I#so"#ia is ,est treate -ith ,e#2oia2epi#e -ith short half-li+es. E.g.
lora2epa"
4e#2oia2epi#es -ith lo#g half-li+es a# ,ar,iturates shoul ,e a+oie
u#less the% are ,ei#g use as part of the treat"e#t for the u#erl%i#g
isorer- e.g.' alcohol -ithra-al.
D.5. DEMENTI$
De"e#tia- is a progressi+e' generalized impairment of intellectual
functions a# memory
-ithout i"pair"e#t of co#scious#ess.
De"e#tias are chro#ic
Etiolog%
De"e#tia has "a#% causes!
De"e#tia of $l2hei"er<s t%pe a# +ascular e"e#tia together represe#t
FDG of all cases.
Other causes of e"e#tia are!
Trau"a 3 hea i#.ur%' repeate hea i#.uries as i# ,o/ers &pu#ch-
ru#1 s%#ro"e)
I#fectio#s 3 e#cephalitis' $DIS e"e#tia co"ple/
Vascular 3 si#gle or "ultiple i#farcts' su,ural hae"ato"a
Meta,olic 3 ure"ia' hepatic failure' h%percalcae"ia
E#ocri#al - h%poth%roiis"
Neoplas"s 3 pri"ar% a# seco#ar% &"etastatic) cere,ral tu"ors
Dege#erati+e 3 $l2hei"er<s isease' ;ic1<s isease' ?u#ti#gto#<s
isease' ;ar1i#so#<s isease
Others 3 Epileps%' a#o/ia' #or"al pressure h%rocephalus' +ita"i#
&4*5) efcie#cies' alcohol' "ultiple sclerosis.
The "a.or efects i# e"e#tia i#+ol+e!
Orie#tatio#
Me"or%
;erceptio#
I#tellectual fu#ctio#i#g
Reaso#i#g
$ll those fu#ctio#s ,eco"e progressi+el% aAecte as the isease process
a+a#ces.
Me"or% i"pair"e#t is t%picall% a# earl% a# pro"i#e#t feature i#
e"e#tia' especiall% i# e"e#tias i#+ol+i#g the corte/' such as
e"e#tia of the $l2hei"er<s t%pe.
Earl% i# the course of e"e#tia' "e"or% i"pair"e#t is "il a# is usuall%
"ar1e for rece#t e+e#ts' such as forgetti#g telepho#e #u",ers'
co#+ersatio#s' a# e+e#ts of the a%.
$s the course of e"e#tia progresses' "e"or% i"pair"e#t ,eco"es
se+ere' a# o#l% the "ost highl% lear#e i#for"atio#- e.g.' place of ,irth is
retai#e.
$s "uch as "e"or% is i"porta#t for orie#tatio# to perso#' place'
a# ti"e' orie#tatio# ca# ,e progressi+el% aAecte uri#g the
course of a e"e#ti#g ill#ess.
e.g.' patie#ts -ith e"e#tia "a% forget ho- to get ,ac1 to their roo"s
after goi#g to the ,athroo".
No "atter ho- se+ere the isorie#tatio# see"s' the patie#t sho-s
#o i"pair"e#t i# the le+el of co#scious#ess.
De"e#ti#g processes that aAect the corte/' pri"aril% e"e#tia of
$l2hei"er<s t%pe a# +ascular e"e#tia' ca# aAect the patie#t<s
la#guage a,ilities.
$phasia is o#e of the iag#ostic criteria.
The la#guage iCcult% "a% ,e characteri2e ,% a +ague'
stereot%pe' i"precise' or circu"sta#tial locutio#.
The patie#t "a% also ha+e iCcult% i# #a"i#g o,.ects.
;re-e/isti#g perso#alit% traits "a% ,e acce#tuate uri#g the
e+elop"e#t of a e"e#tia.
De"e#te patie#ts -ho ha+e para#oi elusio#s are ge#erall%
hostile to fa"il% "e",ers a# careta1ers.
;atie#ts -ith fro#tal a# te"poral i#+ol+e"e#t are li1el% to ha+e
perso#alit% cha#ges a# "a% ,e irrita,le a# e/plosi+e
$# esti"ate 5B-EBG of e"e#te patie#ts' pri"aril% -ith e"e#tia
of the $l2hei"er<s t%pe' ha+e halluci#atio#s' a# EB-4BG of pts
ha+e elusio#s' pri"aril% of para#oi or persecutor% a#
u#s%ste"ati2e #ature. ;h%sical aggressio# a# other for"s of
+iole#ce are co""o# i# e"e#te patie#ts -ho ha+e ps%chotic
s%"pto"s
Treat"e#t
S%"pto"atic treat"e#t i#clues!
The "ai#te#a#ce of #utritious iet
;roper e/ercise
Recreatio#al a# acti+it% therapies
$tte#tio# to +isual a# auitor% pro,le"s
Treat"e#t of associate "eical pro,le"s- such as uri#ar% tract
i#fectio#s' ecu,itus ulcers' a# cariopul"o#ar% %sfu#ctio#.
;articular atte#tio# "ust ,e pro+ie to careta1ers a# fa"il%
"e",ers -ho eal -ith frustratio#' grief' a# ps%chological ,ur#out
as the% care for the patie#t o+er a lo#g perio.
0he# the iag#osis of +ascular e"e#tia is "ae' ris1 factors
co#tri,uti#g to cere,ro-+ascular isease shoul ,e ie#tife a#
therapeuticall% aresse.
Those factors i#clue!-
- ?%perte#sio#
- ?%perlipie"ia
- O,esit%
- Cariac isease
- Dia,etes a#
-alcohol epe#e#ce
;atie#ts -ho s"o1e shoul ,e e#courage to stop' si#ce s"o1i#g
cessatio# is associate -ith i"pro+e cere,ral perfusio# a#
cog#iti+e fu#ctio#i#g.
Curre#t $+aila,le phar"acologic Treat"e#ts
Short acti#g ,e#2oia2epi#e for i#so"#ia a# a#/iet%
$#tiepressa#t for epressio#
$#tips%chotic rugs for elusio#s a# halluci#atio#s
I# ge#eral rugs -ith high a#ticholi#ergics acti+it% shoul ,e
a+oie
E+e# if thioria2i#e ha+e high a#ticholi#ergic acti+it%' it is eAecti+e
i# co#trolli#g ,eha+ior i# e"e#te patie#ts -he# gi+e# i# lo-
osages.
Do#epe2il' Ri+astig"i#e' Gala#ta"i#e' a# Tacri#e are
choli#esterase i#hi,itors use to treat "il to "oerate cog#iti+e
i"pair"e#t i# $l2hei"er<s isease.
The% reuce the i#acti+atio# of the #eurotra#s"itter acet%lcholi#e
a# pote#tiate the choli#ergic #eurotra#s"itter' -hich i# tur#
prouces a "oest i"pro+e"e#t i# "e"or% a# goal irecte
thought.
D.E. $"#estic Disorers
$"#estic Disorers are characteri2e ,% se+ere "e"or%
i"pair"e#t for rece#t e+e#ts.
>o#g-ter" "e"or% is so"eti"es aAecte. I""eiate recall of
e+e#ts is #or"al' as are other cog#iti+e fu#ctio#s.
The patie#t is alert a# co#+ersatio# ca# ,e carrie out #or"all%.
>ear#i#g of #e- "aterial is grossl% aAecte.
Seco#ar% to the "e"or% i"pair"e#t there "a% ,e isorie#tatio#
of ti"e. Gaps i# "e"or% are flle ,% co#fa,ulatio#.
Etiolog%
The co""o#est cause i# cli#ical practice is alcohol a,use' a# is
cause ,% thia"i#e efcie#c%.
Gastric carci#o"a a# ietar% efcie#cies resulti#g i# thia"i#e
efcie#c% prouces a"#estic s%#ro"es.
Da"age to ie#cephalic a# "eial te"poral structures &"a"illar%
,oies' for#i/' hippoca"pus) as a result of surger% or trau"a'
a#o/ia' i#fractio#' i#fectio#s' CO poiso#i#g or #eoplas"s of thir
+e#tricle result i# a"#estic s%#ro"es.
Treat"e#t
The pri"ar% approach is to treat the u#erl%i#g cause of the
a"#estic isorer.
The a"i#istratio# of thia"i#e "a% pre+e#t the e+elop"e#t of
aitio#al a"#estic s%"pto"s' ,ut rarel% is the treat"e#t a,le to
re+erse se+ere a"#estic s%"pto"s' o#ce the% are prese#t.
0hile the patie#t is a"#estic' supporti+e pro"pts regari#g the
ate' the ti"e' a# the patie#t<s locatio# ca# ,e helpful a# ca#
reuce the patie#t<s a#/iet%.
$fter the resolutio# of the a"#estic episoe' supporti+e
ps%chotherap% "a% help patie#ts i#corporate the a"#estic
e/perie#ce i# to their li+es.