P3

• Neurocognitive Disorders


  Disrupts one or more domains of cognition as well as present with behavioral symptoms

  
• Neurocognitive Disorders


  • Delirium
  • Dementia
  • Amnestic disorder
• Delirium


  • May be due to another medical condition, medication induced, or substance induced
  • Presents acutely or suddenly, may present with fluctuating symptoms, waxing or waning
  • Hallmark is impairment of consciousness, usually occurring in association with global impairments of cognitive functions
  • It is a syndrome and not a disease, may present with many causes and is considered a poor prognostic sign, usually considered as the harbinger of death
• Epidemiology of Delirium


  • General medical in patients: 10-30%
  • Medical and surgical in patients: 5-15%
  • Critical care unit patients: 16%
  • Cardiac surgery patients: 16-34%
  • Orthopedic surgery: 33%
  • Terminally ill cancer patients: 23-28%
  • Institutionalized elderly: 44%
• Etiology of Delirium


  • CNS disease
  • Systemic disease
  • Intoxication or withdrawal from pharmacologic or toxic agents
• Factors That May Contribute to Postoperative Delirium


  • Stress of surgery
  • Postoperative pain
  • Insomnia
  • Pain medication
  • Electrolyte imbalance
  • Infection
  • Fever
  • Blood loss
• Other Risk Factors for Delirium


  • Advanced age (65 and older)
  • Pre-existing brain damage (dementia)
  • History of delirium, depression
  • Alcohol dependence
  • Diabetes, Cancer, Stroke, Renal/Hepatic Disease
  • Functional dependence (immobility, falls, low level of activity)
  • Sensory impairment (hearing, visual)
  • Dehydration, Malnutrition
  • Treatment with psychoactive drugs
  • Male gender (independent risk factor)
• Life-Threatening Causes of Delirium: WHHHHIMPS


  • Wernicke's disease
  • Hypoxia
  • Hypoglycemia
  • Hypertensive encephalopathy
  • Hyperthermia or hypothermia
  • Intracerebral hemorrhage
  • Meningitis or encephalitis
  • Poisoning (Exogenous or iatrogenic)
  • Status epilepticus
• Conditions Commonly Associated with Delirium: "I WATCH DEATH"


  • Infectious: Encephalitis, meningitis, syphilis, pneumonia, urinary tract infection
  • Withdrawal: From alcohol or sedative-hypnotics
  • Acute metabolic: acidosis, alkalosis, electrolyte disturbances, liver or kidney failure
  • Trauma: Heat stroke, burns, following surgery
  • CNS pathology: Abscesses, hemorrhage, seizure, stroke, tumor, vasculitis, or normal pressure hydrocephalus
  • Hypoxia: Anemia, carbon monoxide poisoning, hypotension, pulmonary embolus, lung or heart failure
  • Deficiencies: Vitamin B12, niacin, or thiamine
  • Endocrinopathies: Hyper/hypoglycemia, Hyper/hypoadrenocorticism, Hyper/hypothyroidism, Hyper/hypoparathyroidism
  • Acute vascular: Hypertensive encephalopathy or shock
  • Toxins/drugs: Medications, pesticides, or solvents
  • Heavy metals: Lead, manganese, or mercury
• Neurotransmitter involved in Delirium


  Acetylcholine (RAS)
• Neuroanatomical area involved in Delirium

  Reticular formation

  
• Pathway involved in Delirium


  Dorsal tegmental area from the mesencephalic reticular formation extending to the tectum and thalamus
• Reason for delirium from alcohol withdrawal or delirium tremens

  Hyperactivity of the locus ceruleus
• Regardless of the setting, the onset of confusion in elderly patients should trigger concern about infection
• Urinary tract infections (UTIs) and pneumonias are among the most common infections in older patients
• When bacteremia is associated with a UTI, confusion is the presenting feature nearly one third (30%) of the time
• Types of Delirium


  • Hyperactive (30%)
  • Hypoactive (25%)
  • Mixed (45%)
• Hyperactive Delirium


  Psychomotor agitation, increased arousal, repetitive behavior, wandering, hallucinations, and aggression
• Hypoactive Delirium


  Withdrawal, lethargy and reduced arousal
• Patients with hypoactive delirium are often mistaken as having depression and thus are referred to psychiatry as a possible case of major depressive disorder or major depressive episode instead of delirium
• Laboratory Work-Up for Delirium


  • Complete Blood Count (CBC)
  • Blood Chemistry
  • Thyroid Function Tests
  • Serologic test for Syphilis
  • HIV antibody test
  • Urinalysis
  • Electrocardiogram (ECG)
  • Electroencephalogram (EEG)
  • Chest radiograph
  • Blood and urine drug screens
  • Blood, urine, CSF cultures
  • B12, Folic acid levels
  • CT Scan, MRI
  • Lumbar puncture, CSF analysis
• Other Assessments for Delirium


  • Physical Exam
  • Neurologic Exam
  • Mental Status Exam (MSE)
  • Main Mental Status Exam or the Montreal Cognitive Assessment Test (MMSE/MoCA)

  
• Delirium


  Dementia: Delirium has a sudden or acute onset, fluctuation in the level of attention, while dementia is progressive and takes months to years to develop
• Delirium


  Schizophrenia: Delirium has a change in the level of consciousness, while schizophrenia does not
• Delirium


  Depression/Major depressive episode: Delirium has a change in the level of consciousness, while depression/major depressive episode does not
• Symptoms of delirium persist as long as causally relevant factors are present
• Symptoms of delirium usually recede over a 3-7 day period (up to around 2 weeks)
• The older the patient, the longer time they may experience delirium and even after managing the other medical problems, it may take a longer time for the delirium to resolve
• Recall of delirium is often spotty
• Treatment of Delirium


  1. Treat the underlying cause

  2. Provide physical, sensory, and environmental support

  3. For those with Psychosis and insomnia, give a low dose of Haloperidol IV or sometimes oral if possible

  4. Advise the relatives and patient to have advance directives or to assign a health care proxy before they experience delirium

  5. Use hospital rooms with windows, calendars, clock, and a few mementos from home

  6. Use soft and low lighting at night

  7. Have supportive family in attendance

  8. Use physical and/or chemical restraints to protect patients from inflicting harm
• Dementia (Major Neurocognitive Disorder)


  • Progressive
  • Presents with impairment in cognitive functions
  • Patient has clear consciousness
  • Usually presents with global impairment

  
• Treatment for delirium


  1. Treat the underlying cause

  2. Provide physical, sensory, and environmental support

  3. For those with Psychosis and insomnia → pharmacotherapy

  4. For agitated patients, give a low dose of Haloperidol IV or sometimes oral if possible

  5. Advise the relatives and patient to have advance directives or to assign a health care proxy before they experience delirium
• Hospital rooms for delirium


  • Windows, calendars, clock, and a few mementos from home on the walls
  • Soft and low lighting at night
  • Supportive family in attendance
• Physical and/or chemical restraints for delirium


  • Useful to protect patients from inflicting harm on themselves and/or the staff
• Dementia (Major Neurocognitive Disorder)


  • Progressive
  • Presents with impairment in cognitive functions
  • Patient has clear consciousness
  • Usually presents with global impairment of intellect that affects the memory, attention, thinking, and comprehension of the patient

  
• Types of Dementia


  • Alzheimer's type
  • Vascular
  • Secondary to other medical conditions
  • Substance induced
  • Multiple etiologies
• 50-70% of dementia cases are Alzheimer's type
• Vascular dementia is the 2nd most common type, affecting those 60-70 years old, with women more affected than men
• For those >65 years old, the top three types of dementia are Alzheimer's, Vascular, and Mixed vascular and Alzheimer's
• In the Philippines, the estimated prevalence of dementia has almost tripled from 2004 to 2014, and figures are expected to exponentially increase in the next few years