Download Delirium, amnestic syndrome

Delirium
Amnestic syndrom
MUDr.Tomáš Kašpárek
Dep. of Psychiatry
Masaryk University, Brno
Delirium
Characteristics
transient cognitive disorder
core features: impairment of consciousness
with attention deficit, rapid onset, fluctuating
course.
other phenomena may appear more prominent,
but are not always present
– psychomotor changes (agitation), perceptual changes
as illusions and hallucinations, disorganized thought,
delusions, disturbances of sleep, emotional changes
(irritability, flatness of emotions)...
Historical notes
middle ages: phrenitis, frenzy, febrile insanity
19th century:
– „clouding of consciousness“ – lack of clarity of what
it means
– „confusion“ – lack of specificity to delirium
„amency“/acute confusuinal state – terms
describing milder states of delirium, obsolete
50s: attentional and other cognitive
abnormalities are core features, associated with
slowing on the EEG
Risk factors
severity of physical illness
older age
baseline cognitive impairment (dementia)
Etiology
manifestation of brain dysfunction due to systemic or
brain disease or drug intoxication or withdrawal; often
summation of causes
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intoxication - anticholinergics, lithium, hypnotics, alcohol
withdrawal – hypnotics, alcohol
tumor
trauma, subdural hematoma
infection – cerebral, systemic
cardiovascular – cerebrovascular, cardial
metabolic – hypoxemia, electrolyte disturbances, renal or hepatic
failure, hyper/hypoglycemia
– endocrine – thyriod, glucocorticoid disturbances
– nutritional – thiamin, B12 deficiency
Diagnosis
Delirium due to general medical condition
Substance intoxication delirium
Substance withdrawal delirium
Delirium due to multiple etiologies
CRITERIA
– Disturbance of consciousness (reduced clarity of
awareness of the environment) with reduced ability to
focus, sustain ro shift attention
– A change in cognition (memory - recent, language,
disorientation) or a perceptual disturbance not due to
pre-existing dementia
– rapid onset and fluctuating course
Differential diagnosis
Dementia
– include temporal factor (onset, course,
progression)
– no alteration of consciousness
Psychotic, mood, anxiety disorders
– no alteration of consciousness
Treatment
Treatment of primary medical condition
minimizing doses of all sedative and
psychoactive medications (except of alcohol or
sedative withdrawal delirium)
symptomatic control of agitation
– high potency AP (haloperidol)
– avoid low potency AP and sedative agents
(benzodiazepines, antihistaminics) – worsening!!!
– severe, life threatening agitation – sedation with
controlled ventilation
Amnestic disorders
Characteristics
Definition: acquired impaired ability to
learn and recall new information (and past
events sometimes)
No attention deficit or clouding of consciousness
(delirium), no other cognitive dysfunction (dementia)
Secondary syndromes caused by systemic medical or
primary cerebral diseases, substance abuse disorders,
medical adverse effects
Historical notes
Korsakoff
– alcoholic psychosis, ie severe disturbance of mental
status
DSM III, III-R
– memory impairment (short, long-term memory)
DSM IV
– key feature = impaired learning
– distinction vs. dementia: dementia = multiple
impairment
– transient vs. chronic forms (breakpoint = 1 month)
Etiology
Diencephalic and middle temporal lobe structures
(mammillary bodies, hippocampus)
Causes of amnestic syndrome:
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closed head trauma
penetrating missile wounds
focal tumors
surgical intervention
herpes simplex encephalitis
infarction of the territory of the posterior cerebral artery
hypoxia
chronic use of alcohol with thiamine deficiency
Transient forms – linked with CVS disorders, pathology
in the vertebrobasilar system, episodic physiologic or
metabolic disorders, acute intoxications, seizures
Diagnosis
Amnestic disorder due to a General Medical
Condition
Substance-induced persisting amnestic disorder
CRITERIA
– development of memory impairment as manifested by
impairment in the ability to learn new information or
the inability to recall previously learned information
– significant impairment in social or occupational
functioning due to the memory impairment
– memory disturbance does not occur exclusively
during the course of delirium or dementia
Differential diagnosis
Delirium
– memory impairment in the context of impaired
consciousnes and reduced ability to sustain, focus ro
shift attention
– but – amnestic disorder may emerge from delirium
(Korsakoff´s syndrome)
Dementia
– coexistence of memory impairment with multiple
cognitive deficits
Dissociative amnesia
– lack of impaired learning new information –
circumscribed inability to recall previously learned
information with normal functioning in the present
Clinical notes
Transient global amnesia
– episodes of transitory inability to learn new information (to form
memories)
– variable inability to recall memories from the episode
– restoration to completly intact cognitive state
– no behavioral changes x may be confusion, perplexity
sudden/gradual onset – according to the cause (head
trauma, CNS event, chronic toxic exposure)
disorientation – may be to place and time due to severe
mnestic disorder x spared orientation to person
(dementia)
lack of insight
confabulations
Treatment
No effective treatments for amnestic
disorder aimed specifically at learning
deficit
Treat underlying pathological process
– rehabilitation after brain injury
References :
Waldinger R.J.: Psychiatry for medical
students, Washington, DC : American
Psychiatric Press, 1997
Kaplan HI, Sadock BJ, Grebb JA.: Kaplan and
Sadock´s synopsis of psychiatry, Baltimore:
Williams and Wilkins, 1997