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DELIRIUM, DEMENTIA, AND AMNESTIC and OTHER COGNITIVE DISORDERS
 Dementia Definition
 Multiple Cognitive Deficits:
 Memory dysfunction
 especially new learning, a prominent early symptom
 At least one additional cognitive deficit
 aphasia, apraxia, agnosia, or executive dysfunction
 Cognitive Disturbances:
 Sufficiently severe to cause impairment of occupational or social functioning and
 Must represent a decline from a previous level of functioning
 Differential Diagnosis: Top Ten
(commonly used mnemonic device: AVDEMENTIA)
1. Alzheimer Disease (pure ~40%, + mixed~70%)
2. Vascular Disease, MID (5-20%)
3. Drugs, Depression, Delirium
4. Ethanol (5-15%)
5. Medical / Metabolic Systems
6. Endocrine (thyroid, diabetes), Ears, Eyes, Environ.
7. Neurologic (other primary degenerations, etc.)
8. Tumor, Toxin, Trauma
9. Infection, Idiopathic, Immunologic
10. Amnesia, Autoimmune, Apnea, AAMI
 Diagnostic Criteria For Dementia Of The Alzheimer Type (DSM-IV, APA, 1994)
A. Multiple Cognitive Deficits
1. Memory Impairment
2. Other Cognitive Impairment
B. Deficits Impair Social/Occupational
C. Course Shows Gradual Onset And Decline
D. Deficits Are Not Due to:
1. Other CNS Conditions
2. Substance Induced Conditions
E. Do Not Occur Exclusively during Delirium
F. Not Due to Another Psychiatric Disorder
 Alzheimer’s Disease versus Dementia
 50 - 70% of dementias are AD
 Probable AD - 30% of cases, 90% correct
 20% have other contributing diagnoses
 Possible AD - 40% of cases, 70% correct
 40% have other contributing diagnoses
 Unlikely AD - 30% of cases, 30% are AD
 80% have other contributing diagnoses
 Vascular Dementia
(DSM-IV - APA, 1994)
A. Multiple Cogntive Impairments
1. Memory Impairment
2. Other Cognitive Disturbances
B. Deficits Impair Social/Occupational
C. Focal Neurological Signs and Symptoms or Laboratory Evidence Indicating Cerebrovascular Disease Etiologically Related to the Deficits
D. Not Due to Delirium
 Factors Associated with Multi-infarct Dementia
 History of stroke (especially in Nursing Home)
 Followed by onset of dementia within 3 months
 Abrupt onset, Step-wise deterioration
 Cardiovascular disease - HTD, ASCVD, & Atrial Fib
 Depression (left anterior strokes), personality change
 More gait problems than in AD
 MRI evidence of T2 changes (?? Binswanger’s disease)
 Basal ganglia, putamen
 Periventricular white matter
 SPECT / PET show focal areas of dysfunction
 Neuropsychological dysfunctions are patchy
 Post-Cardiac Surgery
 53% post-surgical confusion at discharge (delirium)
 42% impaired 5 years later (dementia)
 May be related to anoxic brain injury, apnea
 May be related to narcotic/other medication
 May occur in those patients who would have developed dementia anyway (? genetic risk)
 Cardio-vascular disease and stress may start Alzheimer pathology
 Any surgery may have a similar effect related to peri-op or post-op anoxia or vascular stress
 Drug Interactions
 Anticholinergics: amitriptyline, atropine, benztropine, scopolamine, hyoscyamine, oxybutynin, diphenhydramine, chlorpheniramine, many anti-histaminics
 May aggravate Alzheimer pathology
 GABA agonists: benzodiazepines, barbiturates, ethanol, anti-convulsants
 Beta-blockers: propranolol
 Dopaminergics: l-dopa, alpha-methyl-dopa
 Narcotics: may contribute to dementia
 Drug Toxicity
 Anti-cholinergic
 Peripheral: blurred vision, dry mouth, constipation, urinary obstruction
 Central: confusion, memory encoding block
 Gaba-agonist:
 Muscle relaxant, anti-convulsant, sedative, anti-anxiety, amnesic, confusion
 Medication induced electrolyte imbalance
 Confusion (watch for in nursing home)
 Depression
 Onset: rapid
 Precipitants: psycho-social (not organic)
 Duration: less than 3 months to presentation
 Mood: depressed, anxious
 Behavior: decreased activity or agitation
 Cognition: unimpaired or poor responses
 Somatic symptoms: fatigue, lethargy, sleep, appetite disruption
 Course: rapid resolution with treatment, but may precede Alzheimer’s disease
 Delirium Definition
(more often a problem in medical in-patients)
 Disturbance of consciousness
 i.e., reduced clarity of awareness of the environment with reduced ability to focus, sustain, or shift attention
 Change in cognition (memory, orientation, language, perception)
 Development over a short period (hours to days), tends to fluctuate
 Evidence of medical etiology
 Delirium
 Susceptibility may be symptom of early dementia, or delirium may predispose to later dementia
 Predisposing factors - Age, infections, dementia
 Medical conditions
 Infections:
 G.U. - urinary
 Respiratory (URI, pneumonia)
 G.I.
 Constipation
 Drug toxicity
 Fracture (especially related to hip fracture)
 Ethanol
 Possibly Neuroprotective
 May not kill neurons directly (?Dietary recommendation?)
 Accidents, Head Injury
 Dietary Deficiency
 Thiamine – Wernicke-Korsakoff syndrome
 Hepatic Encephalopathy
 Withdrawal Damage (seizures) Delayed Alcohol Withdrawal
 Watch for in hospitalized patients
 Chronic Neurodegeneration
 Cerebellum, gray matter nuclei
 Medical / Endocrine
 Thyroid dysfunction
 Hypothyoidism – elevated TSH
 Compensated hypothyroidism may have normal T4, FTI
 Hyperthyroidism
 Apathetic, with anorexia, fatigue, weight loss, increased T4
 Diabetes
 Hypoglycemia (loss of recent memory since episode)
 Hyperglycemia
 Hypercalcemia
 Nephropathy, Uremia
 Hepatic dysfunction (Wilson’s disease)
 Vitamin Deficiency (B12, thiamine, niacin)
 Pernicious anemia – B12 deficiency, ?homocysteine
 Eyes, Ears, Environment
 Must consider sensory deficits might contribute to the appearance of the patient being demented
 Central Auditory Processing Deficits (CAPD)
 Hearing problems are socially isolating
 Visual problems are difficult to accommodate by a demented patient, ?To do cataract op?
 Environmental stress factors can predispose to a variety of conditions
 Nutritional deficiencies (tea & toast syndrome)
 Neurological Conditions
 Primary Neurodegenerative Disease
 Diffuse Lewy Body Dementia (? 7 - 50%)
 Note relation to Parkinson’s disease, symptoms
 Hallucinations, fluctuating course, neuroleptic hypersensitivity)
 Fronto-temporal dementia (tau gene)
 Impaired attention, behavioral dyscontrol
 Decrease blood flow, hypometaboism on SPECT / PET
 (Pick’s disease, Argyrophylic grain disease)
 Focal cortical atrophy
 Primary progressive aphasia (many causes)
 Unilateral atrophy, hypofunction on EEG, SPECT, PET
 Normal pressure hydrocephalus
 Dementia with gait impairment, incontinence
 Suggested on CT, MRI; need tap, ventriculography
 Other Neurologic Conditions
 Subdural hematoma
 Huntington’s disease
 Creutzfeldt-Jakob disease
 Rapid progression
 Characteristic EEG changes
 Multiple sclerosis
 Corticobasal degeneraton
 Cerebellar degeneration
 Progressive supranuclear palsey
 Tumor
 Primary brain tumor
 Meningioma (treatable)
 Glioma (usually not responsive to therapy)
 Metastatic brain tumor
 Remote effects of carcinoma
 Toxins
 Heavy metal screen if considered
 Trauma
 Concussion, Contusion
 Occult head trauma if recent fall
 Subdural hematoma
 Hydrocephalus:
 Normal pressure (late effect of bleed)
 Dementia pugilistica
 Possible contributor to Alzheimer’s disease initiation and progression (? 4% of cases)
 Concern re: physical abuse by caretakers
 Infectious Conditions Affecting the Brain
 HIV
 Neurosyphilis
 Viral encephalitis (herpes)
 Bacterial meningitis
 Fungal (cryptococcus)
 Prion (Creutzfeldt-Jakob disease); (mad cow disease)