undergraduate psychological medicine lecture 2003

1. Psychological
Medicine Block
DELIRIUM, DEMENTIA, AND
AMNESTIC and OTHER
COGNITIVE DISORDERS

2. Lecture Outline
 Cognitive symptoms
 Amnesia, aphasia,
apraxia etc.
 Organic Brain
Syndromes
 Delirium, dementia
and amnestic d/o
 Cognitive Disorders
 Diagnostic criteria
 DAT, VaD
 Management
 BPSD
 Pharmacotherapy
 Psychological

3. Cognitive Symptoms
Amnesia, Aphasia, Apraxia,
Agnosia, Abstraction, and
Attention

4. Types Of Memory
 Declarative
 Semantic
 Episodic
 Non-declarative
 Skills
 Associative learning
 Priming

7. Stages Of Memory
STM LTM
ENCODING / REGISTRATION
Iconic / phonetic
STORAGE / RETENTION
Last seconds to minutes
Limited storage 5-9 items
RETRIEVAL: easier
ENCODING: semantic
STORAGE:
Last for years
Vast storage
RETRIEVAL: more effort

8. Anterograde Amnesia
Past Future
Onset of illnessLTM intact STM consolidation into LTM impaired
INABILITY TO LEARN
NEW INFORMATION

9. Retrograde Amnesia
Past Future
Onset of illnessLTM retrieval impaired STM intact
INABILITY TO RECALL
PREVIOUSLY LEARNED INFORMATION

10. Permanent Or Transient
 Permanent
Encoding failure
Stored Information is lost
 Transient
Transient inability to retrieved stored
information

11. Shrinking Amnesia
Past Future
Time of impact
TRANSIENT TRANSIENTPermanent NormalNormal

12. Organic Amnesia
 STM >> LTM
Anterograde > retrograde
Permanent > transient
Global > selective
Episodic > semantic > autobiographical
Temporal gradient

13. Good
Poor
Remote Recent
Temporal Gradient
Normal forgetfulness
•Decay
•Interference
•Consolidation
•Retrieval failure
Alzheimer’s disease
•STM and LTM impairment
MEMORY
EVENTS

14. Good
Poor
Remote Recent
Temporal GradientMEMORY
EVENTS

16. Psychogenic Amnesia
 Impaired LTM but intact STM
 Memory recovered under hypnosis
E.g., dissociative amnesia
 Autobiographical amnesia but intact
episodic/semantic memory
E.g., dissociative fugue

17. Testing Memory
 Immediate retention and recall:
 Digit span: ability to repeat six figures after examiner dictates them—
first forward, then backward, then after a few minutes' interruption
 Word-list memory tests
 Giving clues (cueing)
 Recent memory:
 past few days, what did patient do yesterday, the day before, have for
breakfast, lunch, dinner
 Recent past memory:
 past few months
 Remote memory:
 childhood data, important events known to have occurred when the
patient was younger or free of illness, personal matters, neutral material

19. OBSERVER
SUBJECT
PAST
PRESENT
Immediate memoryRecent memoryRemote memory
LTM
STM
Attention deficit
Testing Memory

20. Aphasia
 Types of aphasia
 Wernicke’s
 Anomic
 Conduction
 Transcortical sensory
 Broca’s
 Transcortical motor
 Global
 Testing language
 Fluency
 Comprehension
 Repetition
 Naming
 Reading
 Writing

23. Type Description Tests Localization
General Acquired deficit of learned or skilled
movements.
R handers assoc w/aphasia
associated c anosognosia
pantomine for verbal
imitation of pantomime
use of object
Mainly L hemisphere Lesions.
IDEOMOTOR (limb) Usually symmetric to command or
imitation.
Cannot pantomime to command, but
better when actually given object.
Spatial, Postural & orientation errors
temporal errors with inability to slow and
reverse maneuvers.
Salute, wave goodbye,
hitchhike, hammer,
screwdriver, punch,
throw ball, snap
comb hair, brush teeth
Left Inferior Parietal,
Supplementary motor area
Right Hemisphere in L Handers,
Rarely subcortical
CALLOSAL
(Left Hand Ideomotor
apraxia)
Can do verbal commands c Right but
not Left hand,
Can imitation with Both Hands.
(See Ideomotor) Disconnection syndrome,
Ant CC (ie, ACA infarct; genu and
body), Tumor/degendz
(Marchiafava- Bignami Dz)
BUCCO-FACIAL Oral
Often assoc with Broca's
blow out match, cough,
puff out cheeks, whistle
sniff.
L frontal operculum,
ant insula (Broca's area)
rarely supramarginal /angular
IDEATIONAL
(dissociational
apraxia)
Sequential acts
Knows how to perform
AD, Pick's, Posterior corticobasal
degeneration, diffuse Lewy Body
Fold paper, place in
enveloped, stamp.
Cartoons strips in
sequence.
diffuse B lesions
no localizing value
LIMB-KINETIC Unilateral inability to perform fine motor
movements with individual fingers
picking up coin off table Purely corticospinal damage
CONCEPTUAL Brushes teeth with comb
Eats with toothbrush
DRESSING APRAXIA Right parietal
APRAXIA

25. Clock Drawing Test

26. Agnosia
 Loss of meaning to
perception
 Finger agnosia
 Prosopagnosia
SYSTEMS FOR RECOGNITION
 Purpose
 Support recognition of sensory
input
 Anatomy
 Bilateral sensory, visual and
auditory association cortex
 Deficits
 Visual, auditory and tactile
agnosia

27. Executive Functions
 Purpose
 Solve, organize, innovate,
create, supervise, monitor
 Anatomy
 Bilateral prefrontal cortex
 Deficits
 Confabulation,
disorganization, witzelsulcht,
socially inappropriate
behavior, loss of creativity

28. Confabulation
 Unconscious filling of gaps in memory by
imagining experiences or events that have
no basis
 Reflect frontal lobe dysfunction
failure of self-monitoring
 Commonly seen in
amnestic syndromes
dementia

29. Testing Executive Function

30. Wisconsin Card Sorting Test (WCST)

31. Abstraction
 Ability to derive a
general principle from
a specific example
 Testing abstraction
 Similarities
 Difference
 Idioms
 Proverbs

32. Cognitive Functions
 Orientation
 Attention
 Concentration
 Calculation
 Judgment
 Insight
 Memory
 Information
 Abstracting
 Praxis
 Gnostic
 Language

33. Attention & Concentration
 100-7 serial subtraction test
E.g., 100, 93, 86, 79, 72, 65 …
 Digit span test
 Counting day/month backward
 Spelling “world” backward

34. Judgment & Insight
 Judgment
Test, personal and social
 Insight
Symptoms/behavior, illness and treatment
Intellectual and emotional

35. Mini Mental Status Examination
 Orientation
 Time (5)
 Place (5)
 Registration (3)
 Attention &
Calculation (5)
 5-minute recall (3)
 Language
 Naming (2)
 Reading (1)
 Writing (1)
 Repetition (1)
 3 stage command (3)
 Copy drawing (1)

36. ORIENTATION (Score 1 point for correct response)
1. What is the year?
2. What is the season?
3. What is the date?
4. What is the day of the week?
5. What is the month?
6. Where are we? building or hospital?
7. Where are we? floor?
8. Where are we? town or city?
9. Where are we? county?
10. Where are we? state?
REGISTRATION (Score 1 point for each object identified correctly, maximum is 3 points)
11. Name three objects at about one each second. Ask the patient to repeat them. If the patient misses an object,
repeat them until all three are learned.
ATTENTION AND CALCULATION (Score 1 point for each correct answer up to maximum of 5 points)
12. Subtract 7's from 100 until 65 (or, as an alternative, spell "world" backwards).
RECALL (Score 1 point for each correct answer, maximum of 3)
13. Ask for names of three objects learned in question 11.
LANGUAGE
14. Point to a pencil and a watch. Ask the patient to name each object. Score 1 point for each correct answer,
maximum of 2 points.
15. Have the patient repeat "No ifs, ands, or buts." Score one point if correct.
16. Have the patient follow a three-stage command: "(1) Take the paper in your right hand. (2) Fold the paper in
half. (3) Put the paper on the floor." Score 1 point for each command done correctly, maximum of 3 points.
17. Write the following in large letters: "CLOSE YOUR EYES." Ask the patient to read the command and perform
the task. Score 1 point if correct.
18. Ask the patient to write a sentence of his or her own choice. Score 1 point if the sentence has a subject, an
object, and a verb.
19. Draw the design printed below (two intersecting pentagons). Ask the patient to copy the design. Score 1
point if all sides and angles are preserved and if the intersecting sides form a quadrangle.
Mini Mental Status Examination

37. Organic Brain
Syndromes
Delirium, Dementia, and
Amnestic Disorder

38. Functional vs. Organic

39. Delirium – Definition
 Disturbance of consciousness
 i.e., reduced clarity of awareness of the environment
with reduced ability to focus, sustain, or shift attention
 Change in cognition (memory, orientation,
language, perception)
 Development over a short period (hours to
days), tends to fluctuate
 Evidence of medical etiology

41. Systems For Alerting
 Purpose
 Provide arousal for cortical
and subcortical systems
 Anatomy
 RAS: pons, midbrain, and
thalamus
 Deficits
 Lethargy, drowsiness,
coma

42. Delirium – Subtypes
HYPERACTIVE
 Hyperarousal
 Psychotic sx: more
 Behaviour
 Overactivity, irritability,
restless, oversensitive
 Causes
 Alcohol withdrawal
delirium
HYPOACTIVE
 Hypoalert
 Psychotic sx: less
 Behaviour
 Inactivity, speech,
lethargic, sleepy
 Causes
 Metabolic
encephalopathy
Lipowski (1980)

43. Delirium – Etiology
 Delirium is caused by “altered cerebral
metabolism which impairs neuronal functioning”
 Susceptibility may be symptom of early
dementia, or delirium may predispose to later
dementia
 predisposing factors - age, infections, dementia
 Frequently reflects multiple etiologies
 Caused by either direct or indirect effects on the
central nervous system

44. Drug intoxication
Anticholinergics
Lithium
Sedative-hypnotics
Alcohol
Drug withdrawal
Alcohol
Sedative-hypnotics
Tumor
Primary cerebral
Trauma
Cerebral contusion (as an example)
Subdural hematoma
Infection
Cerebral (e.g., meningitis, encephalitis, HIV, syphilis)
Systemic (e.g., sepsis, urinary tract infection, pneumonia)
Cardiovascular
Cerebrovascular (e.g., infarcts, hemorrhage, vasculitis)
Cardiovascular (e.g., low-output states, congestive heart failure, shock)
Physiological or metabolic
Hypoxemia, electrolyte disturbances, hypo- or hyperglycemia, postictal states (as examples)
Endocrine
Thyroid or glucocorticoid disturbances (as examples)
Nutritional
Thiamine or vitamin B12 deficiency, pellagra (as examples)
CAUSES OF DELIRIUM

45. Clinical Presentation (1)
 Cognitive functioning
 perception
 distortions, illusions, hallucinations
 frequently attributed to dreaming and manifest
initially at night
 thinking
 disorangized, fragmented speech patterns,
distracted
 memory
 registry, retrieval & retention impaired

46. Clinical Presentation (2)
 Orientation
 impaired to immediate orientation, recent events, time
of day, etc.; global orientation intact (person, place,
and thing)
 frequently overlooked (e.g., hospital psychosis)
 Attention
 inattentive or hypervigilant
 appear to “drift off” in thought

47. Clinical Presentation (3)
 Wakefulness
*disruption of sleep-wake cycle
 sleep during the day, awake at night
 “sundowning” we go home, they get up
 if not agitated, can mimic depression or anxiety
 Psychomotor behavior
hyperactive vs. hypoactive vs. mixed
 fluctuations

48. Clinical Presentation (4)
 Emotional
Varies from patient to patient in severity,
lability and duration
 anger
 agitation
 anxiety
 depression
Family and friend typically first to notice

49. Differential Diagnosis
 Delirium vs. Depression or Psychosis
Mental status exam
Delusions & Hallucinations
Clouding of consciousness
Psychotic (e.g., schizophrenia) hallucinations
tend to be more organize

50. Dementia Definition
 Multiple Cognitive Deficits:
 Memory dysfunction
 especially new learning, a prominent early symptom
 At least one additional cognitive deficit
 aphasia, apraxia, agnosia, or executive dysfunction
 Cognitive Disturbances:
 Sufficiently severe to cause impairment of
occupational or social functioning and
 Must represent a decline from a previous level of
functioning

51. Delirium vs. Dementia
 Onset: abrupt  insidious
 Duration: days/weeks  years
 Course: fluctuate  progressive
Reversible  irreversible
 Physiological changes: more  less
 Disturbed sleep-wake cycle: more  less

52. Pseudodementia vs. Dementia
 Onset: abrupt  insidious
 Past psych history: yes  no
 Disability: highlight  conceal
 Answer: don’t know  near miss
 Course: fluctuating  stable & progressive
 Mood fluctuation: diurnal  day to day

53. Amnestic Disorder
DSM-IV Criteria
 Memory impairment
 Inability to learn new information, or
 Inability to recall previously learned information
 Memory disturbance significantly impairs social, occupational
function, deterioration from past
 Memory not due to delirium, dementia
 Physiological basis or substance induced
 Distinguish from dissociative disorders, dissociative amnesia,
dissociative identity disorders
 Specify
 Transient – less than 1 month
 Chronic - more than 1 month

54. Amnestic Disorder
Past Future
Onset of illnessLTM impaired STM LTM impaired
INABILITY TO LEARN
NEW INFORMATION
INABILITY TO RECALL
PREVIOUSLY LEARNED INFORMATION

55. Causes of Amnesic Disorders
 Amnesia
 Dissociative: localized, selective, generalized
 Organic - damage to CA1 of hippocampus
 thiamine deficiency (WKE), hypoglycemia, hypoxia
 Epileptic events
 Partial complex seizures
 Specific brain diseases
 Transient global amnesia
 Multiple sclerosis

56. Cognitive Disorders
Dementia of the Alzheimer’s
Type and Vascular Dementia

57. DSM-IV COGNITIVE DISORDERS
Delirium
Delirium due to a general medical condition
Substance-induced delirium
Delirium due to multiple etiologies
Delirium not otherwise specified
Dementia
Dementia of the Alzheimer's type
Vascular dementia
Dementia due to other general medical conditions
Dementia due to HIV disease
Dementia due to head trauma
Dementia due to Parkinson's disease
Dementia due to Huntington's disease
Dementia due to Pick's disease
Dementia due to Creutzfeldt-Jakob disease
Dementia due to other general medical conditions
Substance-induced persisting dementia
Dementia due to multiple etiologies
Dementia not otherwise specified
Amnestic disorders
Amnestic disorder due to a general medical condition
Substance-induced persisting amnestic disorder
Amnestic disorder not otherwise specified
Cognitive disorder not otherwise specified

58. DAT
VaD

59. Dementia of the Alzheimer's Type
(DSM-IV - APA, 1994)
A. Multiple Cognitive Deficits
1. Memory Impairment
2. Other Cognitive Impairment
B. Deficits Impair Social/Occupational
C. Course Shows Gradual Onset And Decline
D. Deficits Are Not Due to:
1. Other CNS Conditions
2. Substance Induced Conditions
E. Do Not Occur Exclusively during Delirium
F. Not Due to Another Psychiatric Disorder

60. AD and Dementia
 50 - 70% of dementias are AD
Probable AD - 30% of cases, 90% correct
 20% have other contributing diagnoses
Possible AD - 40% of cases, 70% correct
 40% have other contributing diagnoses
Unlikely AD - 30% of cases, 30% are AD
 80% have other contributing diagnoses

61. Relative Risk Factors For AD
Family history of dementia 3.5 (2.6 - 4.6)
Family history - Downs 2.7 (1.2 - 5.7)
Family history - Parkinson’s 2.4 (1.0 - 5.8)
Maternal age > 40 years 1.7 (1.0 - 2.9)
Head trauma (with LOC) 1.8 (1.3 - 2.7)
History of depression 1.8 (1.3 - 2.7)
History of hypothyroidism 2.3 (1.0 - 5.4)
History of severe headache 0.7 (0.5 - 1.0)
NSAID use 0.2 (0.05 – 0.83)

62. Functional
impairment
* IADL
* ADL
Insidious onset Cognitive decline
* Memory loss
* Aphasia
* Apraxia
* Agnosia
* Executive
function
difficulties
Behavioral signs
* Mood swings
* Agitation
* Wandering
Age over 60 years
No gait difficulties
AD
Clinical Features of AD

63. Estimate MMSE as a function of time
0
5
10
15
20
25
30
-10 -8 -6 -4 -2 0 2 4 6 8 10
Estimated years into illness
MMSEscore
AAMI / MCI DEMENTIA
ALZHEIMER’S DISEASE

64. Age-Associated Memory Impairment
vs. Mild Cognitive Impairment
 Memory declines with age
 Age - related memory decline corresponds with
atrophy of the hippocampus
 Older individuals remember more complex items
and relationships
 Older individuals are slower to respond
 Memory problems predispose to development of
Alzheimer’s disease

65. Feldman H, Gracon S. In: Clinical Diagnosis and Management of Alzheimer’s Disease. 1996:239-253.
The Progress of Alzheimer’s DiseaseThe Progress of Alzheimer’s Disease
0
5
10
15
20
25
30
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9
Years
MMSEscore
Early diagnosis Mild-moderate Severe
Cognitive symptoms
Loss of ADL
Behavioral problems
Nursing home placement
Death

66. Clinical features of AD
Early Stage (MMSE 21-30)
IMPAIRMENT
Cognition Function Behavior
Recall/learning
Word finding
Problem solving
Judgment
Calculation
Work
Money/shopping
Cooking
Housekeeping
Reading
Writing
Hobbies
Apathy
Withdrawal
Depression
Irritability

67. Clinical features of AD
Intermediate Stage (MMSE 10-20)
IMPAIRMENT
Cognition Function Behavior
Recent memory
(remote memory
unaffected)
Language
Insight
Orientation
Visuospatial ability
Instrumental ADLs
Misplacing objects
Getting lost
Difficulty dressing
Delusions
Depression
Wandering
Insomnia
Agitation

68. Clinical features of AD
Advance Stage (MMSE <10)
IMPAIRMENT
Cognition Function Behavior
Attention
Difficulty performing
familiar activities
(apraxia)
Language (phrases,
mutism)
Basic ADLs
- Dressing
- Grooming
- Bathing
- Eating
- Continence
- Walking
Agitation
Verbal
Physical
Insomnia

69. Neuropathology Of AD
 Senile plaques
 beta-amyloid protein (? Primary problem)
 Neurofibrillary tangles
 hyper-phosphorylated tau (loss of synapses, dementia)
 Neurotransmitter losses
 Acetylcholine (Ach) – major loss of nicotinic receptors
 Norepinephrine, serotonin, glutamate, GABAss
 Inflammatory responses

70. Senile plaques and neurofibrillary tangles

71. Vascular Dementia
(DSM-IV - APA, 1994)
 Multiple cognitive impairments
 Memory impairment
 Other cognitive disturbances
 Deficits impair social/occupational
 Focal neurological signs and symptoms or
laboratory evidence indicating cerebrovascular
disease etiologically related to the deficits
 Not due to delirium

72. Factors Associated with Multi-
Infarct Dementia
 History of stroke
 Followed by onset of dementia within 3 months
 Abrupt onset, Step-wise deterioration
 Cardiovascular disease
 Depression (left anterior strokes), personality
change
 More gait problems than in AD
 Neuropsychological dysfunctions are patchy

73. VASCULAR DEMENTIA CHANGE ON
THE MINI-MENTAL STATE EXAM
OVERTIME
< event
< event
< event
0
10
20
30
-5 0 5 10
AVERAGE TIME OF ILLNESS (years)
SCORE

74. DAT vs. VaD
 Course: progressive  stepwise
 Onset: insidious  acute
 Neurological signs: late  early

75. Management
Cognitive Symptoms & Behavior
and Psychological Symptoms of
Dementia (BPSD)

76. 76

77. Catastrophic Reaction
 It is an emotional outburst involving
various degrees of anger, frustration,
depression, tearfulness, refusal, shouting,
swearing, and sometimes aggression.
 Behavior can be affected by cognitive
defects (Goldstein, 1975)
‘shrinkage of the millieu’, ‘organic ordeliness’
and ‘catastrophic reaction’

78. Behavioral and Psychological Symptoms of Dementia
Most distressing Moderately distressing Manageable
PSYCHOLOGICAL
Delusions
Hallucinations
Depressed mood
Sleeplessness
Anxiety
BEHAVIORAL
Physical aggression
Wandering
Restlessness
PSYCHOLOGICAL
Misidentifications
BEHAVIORAL
Agitation
Culturally inappropriate
behavior and disinhibition
Pacing
Screaming
BEHAVIORAL
Crying
Cursing
Lack of drive
Repetitive questioning

79. Principle of Management
 Treating the cause where possible
 8% of dementia is partially reversible
 Symptomatic treatment
Cognitive symptoms
Behavior & psychological symptoms of
dementia (BPSD)
 Support for caregivers
Many suffer from depression

80. Treating Cognitive Symptoms
 Medication to slow progression
Antioxidants - vitamine E, etc
 Medication to enhance memory
Cholinergic agents - tacrine, donapezil,
rivastigmine
 Non-pharmacological
Notes, familiar surrounding, adequate
stimulation etc

81. Minimizing Confusion
 Familiar person, furniture, house etc
 Structured environment
 Avoid under or over stimulation
 Medication side-effects
 Sundowning phenomena
Tend to become confused at night

82. Reasons For Wandering
 Changed environment
 Loss of memory
 Excess energy
 Searching for the past
 Expressing boredom
 Agitation
 Confusing night with day
 Continuing a habit

83. Communication Guidelines
 Identify self and call
person by name at each
encounter
 Remain calm and talk in a
gentle, matter of fact way
 Keep sentences short
and simple, focusing on
one idea at a time
 Use orienting names
whenever you can such
as “your son ABC”

84. Communication Guidelines
 Don’t argue with the
person.
 Don’t order the person
around
 Don’t tell the person what
they can and can’t do.
Instead state what they
can do
 Don’t ask a lot of direct
questions that rely on a
good memory

85. Validation Therapy
 If a person with dementia
believes that she is
waiting for her children,
all now middle aged, to
return from school
 Family members who use
validation would not
argue the point or expect
their relative to have
insight into their behavior

86. Reminiscence Therapy
 Reminiscence is a
way of reviewing past
events that is usually
a very positive and
rewarding activity
 It them pleasure to be
involved in reflections
on their past