Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline...
Transcript of Delirium & Dementia - smbs.buffalo.edu · Delirium & Dementia Nicholas J. Silvestri, MD. Outline...
Delirium&Dementia
NicholasJ.Silvestri,MD
Outline
• Deliriumvs.Dementia• Neuralpathwaysrelatingtoconsciousness• Encephalopathy• “Stupor”• Coma• Dementia
Deliriumvs.Dementia
• Delirium– Abruptonset– Lastshours-days– Reducedattention– Fluctuatingconsciousness
– Speechdisorganized– Usuallyreversible
• Dementia– Insidiousonset– Lastsmonths-years– Normalattention– Consciousnessintact
– Speechlargelyintact– Usuallyirreversible
UnderlyingPathways
UnderlyingPathways
Encephalopathy
• Theinabilitytomaintainacoherentstreamofthoughtoraction
• Inattentive• Easilydistractible
CausesofEncephalopathy
• Toxic-Metabolic• Infectious• Vascular(e.g.hypertensiveencephalopathy)• Traumatic(e.g.concussion,hemorrhage)• Epileptic(e.g.post-ictalstate)
MetabolicEncephalopathy
• Drugs(EtOH,sedatives,narcotics)• Endocrine(hypo- orhyper- thyroid,glycemia)• Electrolyte(hypernatremia,hypercalcemia)• Nutritional(B1orB12deficiency)• Organsystemfailure(renal,hepatic)
InfectiousEncephalopathy
• Encephalitisvs.meningitis• Importanttoconsideriffeverpresent• Quickinstitutionoftherapynecessary• LowthresholdforLP
Stupor,Obtundation,andOtherBadWords
Coma
• Patientisunconscious• Nopurposefulresponsetotheenvironment– Spontaneous,tocommand,tonoxiousstimuli
• Cannotbearoused• Eyesclosed
EtiologyofComa
• Medical– Diffusehypoxia/ischemia– Dysglycemia– Organfailureordysfunction
– Intoxications– Severeelectrolyteimbalances
– CNSinfections
• Surgical– Intracranialhemorrhage– Intracerebralmasses– Largestrokes– Traumaticbraininjury
BrainDeath
• Irreversiblecessationofallbrainfunction• SynonymouswithdeathinNYS• Causeofcomamustbeknown• Otherconfoundersmustberuled-out– e.g.drugintoxication,hypothermia,etc.
ExaminationinComa
• Assessforarousal• Examineeyes– Pupillaryresponse,cornealresponse,oculocephalic response
• Evaluateforgagreflex• Evaluateforresponsetonoxiousstimuli• Evaluatemotorresponsetonoxiousstimuli
Dementia
• Progressivedisorderofcognitivefunctioninvolvingmemoryandatleastoneothercognitivedomain
CausesofDementia
• Alzheimer’sdisease• Frontotemporaldementia• Lewy Bodydementia• Vasculardementia• Othercauses
Alzheimer’sDisease
• Mostcommoncauseofdementia• Prevalenceincreaseswithage• Usuallysporadic(95%ofcases)
Pathogenesis
• β-amyloid- formsneuritic plaques-extracellulardeposits
• Neurofibrillarytangles- intracellulardepositscontaininghyperphosphorylated τ proteinandubiquitin
• Cholinergicdeficiency– DegenerationofnucleusbasalisofMeynert andseptal-hippocampaltract
Pathology
MRIinAlzheimer’sDisease
ClinicalManifestations
• Early– Recentmemorydifficulty– Anomia(word-findingdifficulty)– Visuospatialdysfunction
• Late– Disinhibition– Psychiatricmanifestations– Eventuallyakinetic mutism
Treatment
• Acetylcholinesteraseinhibitors– Donepezil,rivastigmine,galantamine
• NMDA-glutamatereceptorantagonist–Memantine
• Symptomatictreatment– Forpsychosis,depression,etc.
• Supportivecare
FrontotemporalDementia
• EarlieronsetthanAlzheimer’s• Moreprominentbehavioralthancognitivedysfunctionatonset
• Preferentialatrophyoffrontalandanteriortemporallobes
• Duetoabnormalaccumulationofτ protein• Notreatment
FrontotemporalDementia
Lewy BodyDementia
• Secondmostcommoncauseofdementia• CausedbypresenceofLewy bodiesthroughoutthecortexmadeupofα-synuclein
ClinicalFeatures
• Dementia–MemorylessprominentlyinvolvedthanAlzheimer
• Parkinsonism– Tremor,bradykinesia,rigidity,gaitdysfunction
• Fluctuationofcognition• Visualhallucinations
VascularDementia
• Thirdmostcommoncauseofdementia• Relationshipbetweencerebrovasculardiseaseanddementiaispoorlycharacterized
• Pathogenesis– 1.Multiplestrategicinfarcts– 2.Confluentwhitematterdisease– 3.Both
VascularDementia
VascularDementia
• “Step-wiseprogression”• Treatmentissupportive– Largelyaimedattreatingmodifiablevascularriskfactors(bloodpressure,lipids,diabetes)
OtherCausesofDementia
• Potentiallyreversiblecauses– Hyper- orhypothyroidism– normalpressurehydrocephalus– B12deficiency– neurosyphilis
• Associatedwithotherdisease– Parkinson’sdisease– AIDS
NeurologicalManifestationsofHIV
• Seeninupto70%ofpatientswithHIV/AIDS• Twomajorpathophysiologicmechanisms:– DirecteffectsofHIVonnervoussystem– Opportunisticinfections
Neuro-cognitiveSymptoms
• Subcorticaldementia• Difficultieswithattentionandconcentration• Slowprocessingspeed• Mildshorttermmemorydysfunction• Declineinpsychomotorfunction– Finehandmovements,gaitincooordination
MRIFindings
AIDSDementiaComplex
• a.k.a.HIVencephalopathy• Occurslaterindiseasecourse• Moreseverecognitiveandbehavioraldeficits• CanseewidespreadwhitematterdiseaseandatrophyonMRI
Questions?