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Naming Test (language), Weschler memory scale,
Weschler Adult Intelligence Scale, digit span test
(attention and recall), Wisconsin Card Sorting Test
(executive function), Trail Making A and B (cogni­
tive processing speed), Halstead Battery Category
Test (abstraction), Hachinski ischemia score, and
Delirium Rating Scale.
Diagnosis: Axis I: Delirium, dementia, depres­
sion (pseudodementia), amnesia.
Differential Diagnosis:
Psychiatric: Amnesia, depression, mania, schizo­
phrenia, and normal aging.
Medical: Alzheimer s disease, Lewy Body dis­
ease, Pick s disease, Parkinson s disease, Hunting­
ton s disease, Wilson s disease, vascular demen­
tia, demyelinating disorders, traumatic brain
injuries, cerebral neoplasm, hydrocephalus, CNS
infection, heavy metal poisoning, uremia, hepatic
encephalopathy, hyperthyroidism, hypercalcemia,
vitamin B12 and folate deficiency.
Dementia - Discussion
I. Epidemiology. Alzheimer s disease is respon­
sible for approximately half of all cases of
cognitive impairment in the elderly. Vascular
dementia causes 15 to 20 percent cases of
cognitive impairment in the elderly. Alzheimer s
and vascular dementia together account for the
vast majority of dementia cases. However,
dementias, such as Lewy Body disease, Pick s
disease, Parkinson s disease, HIV-related
dementia, and Huntington s disease, should be
considered in the differential diagnosis. Demen­
tia affects up to 50 percent of the population
over age 85.
II. Etiology
A. Alzheimer s disease is a result of
neuropathological changes that include
amyloid protein deposition. Approximately
40 percent of all patients have a family
history of the disease.
B. Vascular dementia is caused by multiple
infarctions due to atherosclerotic plaques
and thromboemboli occluding cerebral
vessels.
C. Delirium is associated with medical illness
and surgical procedures. Patients with un­
derlying dementia and the elderly are at the
greatest risk of developing delirium.
III.Clinical evaluation
A. The hallmark of dementia is memory loss
(amnesia). Patients may wander in their
neighborhood, pace around their house, and
have difficulties with everyday tasks, such
as dressing or tying shoelaces (apraxia).
They may fail to recognize objects or family
members (agnosia). Language disturbance
can cause word-finding difficulties (aphasia),
and planning and organizational abilities are
often impaired (executive functioning).
B. Alzheimer s disease is more likely than with
other causes of dementia to cause personal­
ity changes and aggressive, irritable, sarcas­
tic, or apathetic behavior.
C. In evaluating a patient with cognitive impair­
ment, the primary task is to rule out delirium
and reversible causes of dementia. The
onset and progression of cognitive decline
provide important clues to the diagnosis.
Patients with Alzheimer s dementia typically
demonstrate a gradual, progressive decline
in cognitive functioning.
D. Vascular dementia shows a more stepwise
decline in functioning where each infarct
causes abrupt impairment. Delirium causes
a sudden onset of mental status changes
with altered level of consciousness and a
rapidly fluctuating course, although the
symptom presentation is similar to dementia.
IV. Treatment
A. Agitated behavior is the most common
reason for admission for patients with de­
mentia or delirium.
B. Alzheimer s disease is treated with
cholinesterase inhibitors for symptomatic
improvement and to possibly slow cognitive
decline.
C. Vascular dementia is treated by reducing
risk factors, such as hypertension,
hyperlipidemia, diabetes, smoking, and
obesity.
D. Atypical antipsychotics are used to treat
delusions, hallucinations, and agitated be­
havior associated with dementia. Delirium
requires treatment of the underlying etiology.
E. Supportive psychotherapy may help pa­
tients and their families to cope with the
stress associated with loss of autonomy,
declining health, and impaired cognitive
functioning.
References, see page 92.
Delirium - History Taking
History of present illness: Assess impaired
consciousness; fluctuating levels of conscious­
ness, arousability, ability to sustain attention,
ability to focus, and reduced clarity of awareness
of the environment. Ask about current symptoms,
nature of onset, causative precipitants, and dura­
tion; delirium develops over a short period of time
and symptoms fluctuate over the course of the
day. Assess cognitive changes, such as, memory
impairment, disorientation, and language distur­
bance.
Ask about abnormalities of mood (eg, anger),
perception (eg, visual hallucinations), and behav­
ior (eg, agitation). Assess psychomotor distur­
bance, such as hyperactivity with increased startle
response, flushing, sweating, tachycardia, nau­
sea, vomiting, and hyperthermia. Hypoactivity may
manifest with slowed reaction time, catatonia, and
depression.
Language disturbance may include rambling,
changes in the flow of speech, or incoherent
speech. Ask about sleep disturbance; insomnia,
nightmares, hypnopompic and hypnagogic halluci­
nations, reversal of the sleep-wake cycle, daytime
drowsiness, and exacerbation of symptoms at
night (ie, sundowning).
Past psychiatric history: Ask about previous
delirious episodes, psychotic symptoms in the
past, and a history of transient cognitive impair­
ments associated with medical illness or surgery.
Substance abuse history: Alcohol intoxication
and withdrawal may cause cognitive impairment,
delirium, amnesia, and psychotic symptoms. Ask
about all substances used, extent of use, and
history of withdrawal symptoms. Alcohol depend­
ence increases the risk of developing delirium.
Social history: Ask about housing, employment,
extent of family support, marital status, and chil­
dren.
Family history: Ask about family history of psy­
chiatric illness and dementia. Delirium does not
occur more frequently among family members
unless the underlying etiology is heritable.
Past medical history: Assess history of seizure [ Pobierz całość w formacie PDF ]