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Chapter Fifteen - Cognitive Disorders.docx

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David Moscovitch

[ FIFTEEN ] – COGNITIVE DISORDERS PERSPECTIVES  3 classes of cognitive Ds: - delirium = often temporary condition displayed as confusion and disorientation - dementia = progressive condition marked by gradual deterioration of broad range of cognitive abilities - amnestic disorders = dysf’ns of memory due to medical condition/drug/toxin  Used to be called organic mental disorders but term covered so many as to make distinction meaningless DELIRIUM  Characterized by impaired consciousness and cognition during course of several hours/days  One of the earliest recognized mental Ds  DSM-IV criteria: a) person exp’s disturbance of consciousness (i.e. reduced clarity of awareness of env’) w/ reduced ability to focus/sustain/shift attention b) person exp’s change in cognition (such as memory deficit, disorientation, lang disturbance) or dvlpmt of perceptual disturbance tht is not better acc’d for by pre-existing/established/evolving dementia c) disturbance dvlps over short period (usually hrs/days) and tends to fluctuate during course of day d) evidence from hist/phys exam/lab findings tht disturbance caused by direct physiological consequences of general medical condition  Subtypes: substance-induced delirium, delirium due to multiple etiologies, delirium NOS  Estimate: present in 10-30% of those who come into acute care facilities such as emergency rooms  Prevalence in emergency dptmt patients 65+ yrs abt 10%  Most prevalent among older adults, ppl undergoing medical procedures, cancer patients, and ppl w/ acq’d immune deficiency syndrome  Common risk factors in older patients include dementia, meds (i.e. those w/ anticholinergic effects used to counteract extrapyramidal side effects of neuroleptic meds), and medical illness (i.e. intoxication by drugs and poisons; w/drawal from drugs; infections; head injury; various types of brain trauma)  Subsides relatively quickly, w/ full recovery expected in most cases w/in several weeks  Minority cont’ to have problems on & off, and fewer still lapse into coma & may die - symptoms often present during last several hrs of life among terminally ill patients  May be exp’d by children who have high fevers or who are taking certain meds and often mistaken for noncompliance  Older adults more susceptible aar mild infections or meds changes - thus, age can be considered marker since i↑’g age associated w/ specific physiological changes tht may themselves i↑ risk  Sleep deprivation, immobility and excessive stress can also be a cause  Env’ factors role in risk i.e. hospital room changes can disrupt older patient’s ability to correctly perceive env cues, resulting in misinterpretation of stimuli Treatment  Rapid trtmt important as quicker in-hospital recovery associated w/ better LT outcomes  Acute delirium and delirium brought on by drug & alcohol w/drawal: haloperidol or other antipsychotic meds, which help calm indvdl  Infections, brain injury, and tumours given necessary and appropriate medical intervention  Psychosocial intervention: reassure person to help deal w/ agitation, anxiety and hallucinations of delirium - patient included in all trtmt decisions, retaining sense of ctrl Prevention  Proper medical care for illnesses and therapeutic drug monitoring  Interventions: edu, support, reorientation, anxiety-reduction, preoperative medical assessment DEMENTIA  Gradual deterioration of brain f’n’g tht affects judgment, memory, lang, and other advanced cognitive processes  Caused by several medical conditions (i.e. stroke, syphilis, HIV, severe head injury, intro of certain toxic/poisonous substances, Parkinson’s, Huntington’s, Alzheimer’s disease) and by abuse of drugs/alcohol  Progression varies per indvdl & cause of D  Initially, memory impairment seen as inability to register ongoing events  Familiar symptoms: - agnosia = inability to recognize and name objects - facial agnosia = inability to recognize even familiar faces  Intellectual deterioration f’n results from impairment in memory, planning & abstract reasoning  Perhaps b/c victims aware they are deteriorating mentally. Emotional changes often occur as well - common side effects: delusions (irrational beliefs), depression, agitation, agg’n, apathy  Cog f’n’g cont’s to deteriorate until person req’s almost total support to carry out day-to-day activities  Ultimately, death aar of inactivity combined w/ onset of other illnesses  Can occur at almost any age  Incidence highest in older adults  Rate ~ for M & F and equivalent across edu level and social class  Dementia of Alzheimer’s type may be more prevalent among women  5 classes of dementia: i.) dementia of the Alzheimer’s type ii.) vascular dementia iii.) dementia due to other general medical conditions iv.) substance-induced persisting dementia v.) dementia due to multiple etiologies Dementia of the Alzheimer’s Type  DSM-IV criteria: a) dvlpmt of multiple cognitive deficits manifested by both: i) memory impairment (impaired ability to learn new info or ot recall previously learned info) ii) 1/more of following cognitive disturbances: aphasia (lang disturbance); apraxia (impaired ability to carry out motor activities despite intact motor f’n); agnosia (failure to recognize/identify objects despite intact sensory f’n); disturbance in executive f’n’g (i.e. planning, organizing, sequencing, abstracting) b) course characterized by gradual onset and cont’g cognitive decline c) cognitive deficits not due to: i.) other CNS conditions tht cause progressive deficits in memory and cognition (i.e. cerebrovascular disease, Parkinson’s, Huntington’s, brain tumour) ii.) systemic conditions known to cause dementia (i.e. vitamin B12 or folic acid deficiency, HIV infection) iii.) substance-induced conditions  Tend to lose interest in others and aar, become more socially isolated  As it progresses, can become agitated, confused, depressed, anxious, or even combative  Sundowner syndrome = difficulties become more pronounced late in the day (perhaps aar fatigue/disturbance in brain’s biological clock)  To diagnosis for it: - Mini Mental State Examination = simplified v. of mental status exam to assess lang & memory problems; make diagnosis w/o direct examination of brain - supplementary, use clock-drawing subtest of Clock Test  Cognitive deterioration slow during early & later stages, but rapid during middle  Median survival after onset only 3 yrs  Usually appears during 60s or 70s  Abt 50% dementia cases ultimately found to be result of Alzheimer’s  Cerebral reserve hypothesis = the more synapses a person dvlp’s t/o life, the more neuronal death must take place before signs of dementia are obvious  More prevalent among women (possibly loss of estrogen as they age, so perhaps was protective) Vascular Dementia  DSM-IV ~ to Alzheimer’s (but NOT characterized by gradual onset and cont’g cognitive decline), and: - person exhibits focal neurological signs and symptom
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