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Dementia and Delirium

Dementia and Delirium. By Dr: Hazem Alhewag Ass. Professor of Neurology Sohag Faculty of Medicine. Definition. Multiple impairment of cognitive function which must include memory and leading to Impairment in social and/or occupational functions and Not explained by another disorder.

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Dementia and Delirium

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  1. Dementiaand Delirium By Dr: Hazem Alhewag Ass. Professor of Neurology Sohag Faculty of Medicine

  2. Definition • Multiple impairment of cognitive function which must include memory and leading to Impairment in social and/or occupational functions and Not explained by another disorder

  3. Impairment Cognitive function • At least one of the following: • Aphasia - language impairments • Apraxia - motor memory impairments • Agnosia - sensory memory impairments • Abstract thinking / Exec. function impairments

  4. Etiology & Pathogenesis • Dementia results from impaired functioning of multiple brain systems in both cortical and sub-cortical areas that are associated with short-term memory (i.e. learning) and other higher cognitive functions. Generally this is due to structural brain damage that is often progressive and relatively irreversible

  5. Most Common Dementias • Alzheimer’s Disease and Lewy Body Dementias (50-75%) • Vascular Dementias (15-20%) • Alcohol-related dementias • HIV dementia

  6. Other less common dementias • Primary degenerative dementias • Diffuse Lewy Body dementias (7-26% of dementias) • Frontotemporal dementias (Pick’s, ALS, Huntington’s) • Neurological disordersassociated with dementia • PSP, Parkinson’s dementia, NPH, neoplasm, head trauma, demyelinating diseases

  7. General medical causes of dementia • Thyroid and adrenal diseases • Vitamin deficiency states (thiamin, niacin, B12) • Metabolic derangements (hepatic encephalopathy, dialysis dementia, etc.) • Medications (sedatives, narcotics, anticholinergics) • Whipple’s Disease, sarcoidosis, Wilson’s disease • Toxins (heavy metals, organic poisons • Head trauma

  8. Risk factors of dementia • Genetic risk factors • Chromosome 19 - autosomal recessive - Apolipoprotein E-4 allele - associated with late-onset disease • Chromosome 1, 14, 21 - autosomal dominant mutations - associated with early-onset/familial cases. Amyloid processing genes. • Chromosome 9 – ‘ubiquilin 1’ polymorphisms

  9. Additional Risk Factors for Dementia • Cerebrovascular disease (and the risk factors for CV disease – including smoking, diabetes, hyperlipidemia, hypertension) is associated with vascular dementia risk • Recurrent MDD may be associated with risk of dementia in general. • Subclinical Hyperthyroidism (especially when antithyroid antibodies are present. • low education level

  10. Classification of Dementias • Primary versus secondarybased on the pathophysiology leading to damaged brain tissue • Cortical versus sub-corticaldepending on the cerebral location of the primary deficits • Reversible versus irreversibledepending on optimal treatment expectations • Early versus late onset before age 65

  11. Clinical Presentation Memory Impairments: • Difficulty learning or retaining new information (repeated conversations) • Information retrieval deficits (can’t recall names)

  12. Language Deficits • Word-finding difficulties (naming problems) • Verbal fluency deficits ( empty speech or meaning less speech) • Less complex sentence structure (agramatic sentence)

  13. Visuospatial impairments • Visual recognition impairments (visual agnosia) trouble recognizing familiar faces - CAPGRAS syndrome possible • Spatial deficits( sensory agnosia)getting lost in familiar surroundings, 3-D drawing deficits

  14. Executive Function Impairments • Planning, correlating, abstracting –( Frontal lobe Function) • Taking multiple threads of information and processing it to make a decision • Often the first impairment noticed in highly educated/intelligent people

  15. Functional Impairments Instrumental Activities of Daily Living (IADL’s) • Telephone, Travel, Shopping, • Eating, housework, Medicine, Money, Bathing • • Dressing, Grooming, Toileting • • Continence, • Transferring

  16. Behavioral Symptoms PERSONALITY CHANGE • Occurs early • apathy, social withdrawal • disinhibition (inappropriate sexual behavior or language) • (childishness Agitation Depression Psychosis Sleep disturbance

  17. vascular Subcortical History of stroke Pyramidal sings Dysarthia Stepwise progression modifiable Alzheimer Cortical No history of cvs No pyramidal sings Aphasia Slowly progression Non modifiable Vascular Vs Alzheimer dementia

  18. DIFFERENTIAL DIAGNOSIS • Age-related cognitive impairment: Benign Senescent Forgetfulness or Mild Cognitive Impairment (MCI). Symptoms not currently associated with functional impairment.. • Delirium - Impairments of consciousness and attention. • Pseudodementia : ass. With depression

  19. DELIRIUM • Acute brain dysfunction characterized by • Waxing and waning levels of consciousness • Poor attention and disorientation • Disturbed memory (long and short term) • Psychosis • Sleep dysregulation • Agitation and aggression • Seriously impaired insight and judgment

  20. Causes of Delirium • Infections, trauma, brain diseases • Cardiac diseases, lung disease, hypoxia, hypoglycemia • Toxins, or intoxications • Medication effects • Substance withdrawals • Endocrinopathies

  21. Delirium vs Dementia • General rules of thumb: DeliriumDementia acute chronic reversible irreversible physiological structural primary attention primary memory deficits deficits

  22. Diagnostic Approach • Careful history from patient and reliable informant • Neurological exam and cognitive testing as MMSE (score 30 ) less than 22 dementia • Functional Assessment tools such as the Functional Activities Questionnaire

  23. Diagnostic Work-Up • This is done to • (1) rule out disorders besides dementia, • (2) to identify reversible/treatable dementias (13%) • (3) to clarify the specific dementia syndrome • Routine Assessment:CBC with diff, serum electrolytes, glucose, BUN/CR, LFTs, TFTs, B12 & folate, neuroimaging, • When indicated: HIV, heavy metals, LP, EEG, endocrine studies

  24. Primary Treatment Strategies Prevention • Correction of risk factors • Neuroprotection as: • Nerve Growth Factor • Estrogen • Antioxidants (Vit E, Gingko) • ‘Statins’ • anti-inflammatory • Physical and mental exercise

  25. Specific treatment (cognitive enhancers) • Acetylecholine esterase inhibitors: Donpezil Rivastegmine • NMDA antagonist Memantine

  26. Symptomatic treatment • Depression • Psychosis • agitation

  27. Thank you

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