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Lecture 41
DEMENTIA DELIRIUM AND AMNESTIC DISORDERS
Recap lecture no 40
·  Formerly called organic mental disorders now the new name according to DSM-IV-TR is cognitive
disorders or cognitive impairment disorders.
·  It includes Delirium, Dementia and Amnesia.
Dementia
Dementia is a gradual worsening loss of memory and related cognitive functions, including the use of
language, as well as reasoning and decision making.
Delirium
Delirium is a state of confusion and disorientation that develops over a short period of time and is often
associated with agitation and hyperactivity.
Amnesia
People with Amnesia disorders experience memory impairments that are more limited than those seen in
dementia or delirium.
Research on brain and its role on psychopathology have increased in recent years. The term organic mental
disorder was dropped and the term cognitive mental disorder was adopted.
Cognitive disorders signify the impairment of cognitive abilities such as
·  memory
·  attention
·  perception
·  thinking
Cognitive disorders generally first appear during the patient's 50's or 60's and accelerate after the age of 70.
Cognitive impairment disorders include
·  Dementia
·  Delirium
·  Amnesia
Some degenerative brain diseases include
1. Alzheimer's dementia
2. Parkinson's disease
3. Huntington's disease
4. Pick's disease
Causes of Cognitive Impairment Disorders
1. old age
2. improper use of medications
3. head injuries
4. Various types of brain traumas.
Treatment of Cognitive Impairment Disorders
1. Treatment of the Patient
a. Psychotropic Medications
b. Behavioral Programs
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c. Cognitive Rehabilitation
2. Treatment of Caregivers
·  Because of the close link between cognitive disorders and brain disease, patients with these
problems are often diagnosed and treated by neurologists, physicians who deal primarily with
diseases of the brain and the nervous system.
·  Multidisciplinary clinical teams study and provide care for people with dementia and amnestic
disorders.
·  Direct care to patients and their families is usually provided by nurses and social workers.
·  Neuropsychologists have particular expertise in the assessment of specific types of cognitive
impairment.
·  Changes in emotional responsiveness and personality typically accompany the onset of memory
impairment in dementia.
·  In some cases, personality changes may be evident before the development of full-blown cognitive
symptoms.
Assessment of Cognitive Impairment
There are many ways to measure a person's level of cognitive impairment.
a. One is the Mini-Mental State Examination.
·  Some of the questions on this exam are directed at the person's orientation to time and place.
·  Others are concerned with anterograde amnesia, such as the ability to remember the names of
objects for a short period of time.
b. Neuropsychological assessment can be used as a more precise index of cognitive
impairment.
·  This process involves the evaluation of performance on psychological tests to indicate whether a
person has a brain disorder.
·  The  best-known  neuropsychological  assessment  procedure  is  the  Halstead-Reitan
Neuropsychological Test Battery, which includes an extensive series of tests that tap sensorimotor,
perceptual, and speech functions.
·  Some neuropsychological tasks require the person to copy simple objects or drawings.
c. Personality and Emotion
·  The emotional consequences of dementia are quite varied.
·  Some demented patients appear to be apathetic or emotionally flat.
·  At other times, emotional reactions may become exaggerated and less predictable.
·  Depression is another problem that is frequently found in association with dementia.
d. Motor Behaviors
·  Demented persons may become agitated, pacing restlessly or wandering away from familiar
surroundings.
·  In the later stages of the disorder, patients may develop problems in the control of the muscles by
the central nervous system.
·  Some specific types of dementia are associated with involuntary movements, or dyskinesia--tics,
tremors, and jerky movements of the face and limbs called chorea.
Amnesia
·  Some cognitive disorders involve more circumscribed forms of memory impairment than those
seen in dementia.
·  In amnestic disorders, a person exhibits a severe impairment of memory while other higher level
cognitive abilities are unaffected.
·  The memory disturbance interferes with social and occupational functioning and represents a
significant decline from a previous level of adjustment.
·  The most common type of amnestic disorder is alcohol-induced persisting amnestic disorder, also
known as Korsakoff's syndrome.
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·
In this disorder, which is caused by chronic alcoholism, memory is impaired but other cognitive
functions are not.
·
One widely accepted theory regarding this condition holds that lack of vitamin B1 (thiamine) leads
to atrophy of the medial thalamus.
Brief Historical Perspective
·  Alois Alzheimer, a German psychiatrist, worked closely in Munich with Emil Kraepelin, who is
often considered responsible for modern psychiatric classification.
·  Alzheimer's most famous case involved a 51-year-old woman who had become delusional and also
experienced a severe form of recent memory impairment, accompanied by apraxia and agnosia.
·  This woman died 4 years after the onset of her dementia.
·  Following her death, Alzheimer conducted a microscopic examination of her brain and made a
startling discovery: bundles of neurofibrillary tangles and amyloid plaques.
·  Alzheimer presented the case at a meeting of psychiatrists in 1906 and published a three-page paper
in 1907.
·  Emil Kraepelin began to refer to this condition as Alzheimer's disease in the eighth edition of his
famous textbook on psychiatry, published in 1910.
·  Until recently, the diagnostic manual classified the various forms of dementia as Organic Mental
Disorders because of their association with known brain diseases.
·  In order to be consistent with the rest of the diagnostic manual, and so as to avoid falling into the
trap of simplistic mind­body dualism, dementia and related clinical phenomena are now classified
as Cognitive Disorders in DSM-IV-TR.
·  These disorders are divided into three major headings: deliria, dementias, and amnestic disorders.
Frequency of Delirium and Dementia
·  The incidence of dementia will be much greater in the near future, because the average age of the
population is increasing steadily.
·  By the year 2030, more than 9 million people in the United States will be affected by Alzheimer's
disease.
·  Epidemiological studies must be interpreted with caution, of course, because of the problems
associated with establishing a diagnosis of dementia.
·  Definitive diagnoses depend on information collected over an extended period of time so that the
progressive nature of the cognitive impairment, and deterioration from an earlier, higher level of
functioning, can be documented.
·  Unfortunately, this kind of information is often not available in a large-scale epidemiological study.
·  Also bear in mind the fact that the diagnosis of specific subtypes of dementia requires microscopic
examination of brain tissue after the person's death.
Prevalence of Cognitive Impairment Disorders
·  Studies of community samples in North America and Europe indicate that the prevalence of
dementia in people between the ages of 65 and 69 is approximately 1 percent.
·  For people between the ages of 75 and 79, the prevalence rate is approximately 6 percent, and it
increases dramatically in older age groups.
·  Almost 40 percent of people over 90 years of age exhibit symptoms of moderate or severe
dementia.
·  Survival rates are reduced among demented patients.
·  There are no obvious differences between men and women with regard to the overall prevalence of
dementia, broadly defined.
·  It seems, however, that dementia in men is more likely to be associated with vascular disease or to
be secondary to other medical conditions or to alcohol abuse.
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·
Alzheimer's disease appears to be the most common form of dementia, accounting for perhaps half
of all cases.
·
Dementia with Lewy bodies may be the second leading cause of dementia; studies report
prevalence rates between 12 and 27 percent for DLB among patients with primary dementia.
·
Prevalence rates for vascular dementia are similar to those for DLB.
·
Pick's disease is much less common than Alzheimer's disease, vascular dementia, or DLB.
·
Huntington's disease is rare by comparison.
·
It affects only 1 person in every 20,000.
Cross cultural Comparisons
·  Alzheimer's disease may be more common in North America and Europe, whereas vascular
dementia may be more common in Japan and China.
·  There are also some tentative indications that prevalence rates for dementia may be significantly
lower in developing countries than in developed countries.
Treatment and Management
·  When a person clearly suffers from a primary type of dementia, such as dementia of the
Alzheimer's type, a return to previous levels of functioning is extremely unlikely.
·  No form of treatment is presently capable of producing sustained and clinically significant
improvement in cognitive functioning for patients with Alzheimer's disease.
·  Realistic goals include helping the person to maintain his or her level of functioning for as long as
possible in spite of cognitive impairment and minimizing the level of distress experienced by the
person and the person's family.
1. Medication
·  Some drugs are designed to relieve cognitive symptoms of dementia by boosting the action of
acetylcholine (ACh), a neurotransmitter that is involved in memory and whose level is reduced in
patients with Alzheimer's disease.
·  New drug treatments are being pursued that are aimed more directly at the processes by which
neurons are destroyed.
·  Although the cognitive deficits associated with primary dementia cannot be completely reversed
with medication, neuroleptic medication can be used to treat some patients who develop psychotic
symptoms.
2. Environmental and Behavioral Management
·  Patients with dementia experience fewer emotional problems and are less likely to become agitated
if they follow a structured and predictable daily schedule.
·  Severely impaired patients often reside in nursing homes and hospitals.
·  The most effective residential treatment programs combine the use of medication and behavioral
interventions with an environment that is specifically designed to maximize the level of functioning
and minimize the emotional distress of patients who are cognitively impaired.
·  One important issue related to patient management involves the level of activity expected of the
patient.
·  It is useful to help the person remain active and interested in everyday events.
·  Patients who are physically active are less likely to have problems with agitation, and they may sleep
better.
·  Social interactions are often troublesome for patients with dementia due to distorted views of
reality.
·  Creative problem-solving strategies that accommodate the patient's distorted view of reality are
sometimes useful in this type of situation.
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3. Support for Caregivers
·  In the United States, spouses and other family members provide primary care for more than 80
percent of people who have dementia of the Alzheimer's type.
·  Their burdens are often overwhelming, both physically and emotionally.
·  In addition to the profound loneliness and sadness that caregivers endure, they must also learn to
cope with more tangible stressors, such as the patient's incontinence, functional deficits, and
disruptive behavior.
·  Some treatment programs provide support groups, as well as informal counseling and ad hoc
consultation services, for spouses caring for patients with Alzheimer's disease.
·  Some treatment programs arrange for direct assistance in addition to social support.
·  Respite programs provide caregivers with temporary periods of relief away from the patient.
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