THE COGNITIVE DISORDERS Brian E. Wood, D.O. Associate Professor and Chair Department of...
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THE COGNITIVE DISORDERS
Brian E. Wood, D.O.Associate Professor and Chair
Department of Neuropsychiatry and Behavioral SciencesEdward Via Virginia College of Osteopathic Medicine
[email protected] Associate Professor of Psychiatry and Neurobehavioral Sciences
University of Virginia School of Medicine
2/2012
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The Clinical Workup
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Mental Status
SpeechMood and Affect
Behavior
Perception
Thought
Memory and Cognition
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PHYSICAL EXAM
Mental Status Exam
General Description
Mood and Affect
Thought
Perception
Memory and Cognition
The Mental Status Exam
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Cognitive AssessmentSo, How Do We Start?
• Subjective assessment of cognition– May be very sensitive and is often useful– Not reproducible and difficult to compare
• Objective Assessment of Cognition– Often useful for reproducibility and comparison– Sometime overlooks subtleties
• Combination Assessment can take advantage of strengths of both and provide context.
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Objective Screens of Cognition
• Screen area of Cognition (well validated)• Provides quantified data
– allows professionals to “speak the same language” ( reliability)
– Reproducible– Provides data for comparison and tracking particularly
of serial examinations.
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Cognitive Screening Instruments
• MOCA• Folstein Mini Mental State
Exam• SLUMS• Mini-Cog• ADAS-COG• Other neuropsychiatric
screens.
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Other Clinical Elements for Differential Diagnosis
• Cognitive Impairment• Acquired vs. Congenital• Reversible vs. Irreversible• Other Psychiatric Illnesses
• Depression, primary psychotic disorders• Primary Cognitive Illnesses– Dementias– Delirium– Amnestic Syndromes
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The Dementias…..
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Dementia: What is it?
• Primarily cortical disease or results from cortical disruption.– Cortical neuronal loss– Disruption of communication pathways
• General class of diseases, probably many illnesses that present with Dementia.
• May be a common pathway of brain disease.
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How Do We Make the Diagnosis?
• Work up– History (general medical, family, social)– Complete examination including thorough mental
status examination– Labs and testing
• Differential Diagnosis
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DSM IV TR Criteria for Dementia
• Memory impairment• One or more of the following:
– aphasia– apraxia– agnosia– disturbance in executive functioning (planning, sequencing)
• Decline in cognitive functioning• Functional impairment
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Amnestic SyndromesMCI, AAMI, etc.
• Isolated memory deficits• Does not meet criteria for dementia because other
cortical dysfunctions are not present.• Needs to be differentiated from Cognitive Disorder
NOS (MCI) and Dementia which are characteristically different diseases
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Other Dementia Criteria
• Illness vs. Phenomenalogical models– Often making a clinical diagnosis based on symptoms.
• Clinical Probability models– Consensus criteria– More symptoms = greater likelihood of disease– May add thresholds (ex. DSM)
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Alzheimer’s Dementia• Most common• Definitive Diagnosis with brain
tissue only
– usually diagnosis of “probable” AD
– Correct about 85% of time
• insidious onset and progressive course
Alois Alzheimer
Auguste Deter
Emil Kraepelin
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Dementia with Lewy Bodies
• Prevalence varies according to criteria.• Arguable existence• Clinically distinct from AD
– variations in alertness and attention– prominent visual hallucinations.– Motor features of Parkinsonism (EPS)
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Vascular Dementia• Multiple clinical
variations depending on location of lesions.
• Classic “stepping off” phenomena associated with multi-infarct variety
• May look clinically similar to other Dementias.
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ETOH Dementia
• Diagnosis by history of ETOH abuse/dependence.• Neuro-toxic effects of Alcohol. • Classic presentation of “spotty” cognitive loss.• Korsakoff’s syndrome:
– confabulation– rambling, garrulous speech
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Other Dementias
• Pick’s disease (FTD)• Creutzfeldt-Jakob disease• Parkinson’s Disease (PD)• Secondary Dementias• Mixed Dementias
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Treatment
• Supportive treatment (medical and psychosocial)• Minimize complications• Treatment of secondary neuropsychiatric symptoms
(depression, psychosis, etc.)• Cholinesterase inhibitors (donepezil, rivastigmine and
galantamine) • NMDA receptor blockers (memantine) block rapid glutamate
uptake in the neuron
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The Future: What does it hold?• Increasing emphasis on genetic
markers – possible genetic treatment
• Much more specific pharmacologic treatment
• Better understanding of relationships to other psychiatric illnesses and treatments.
• Increased social awareness of needs.
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Delirium
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Disease Characteristics• Disease of the subcortical areas of the
brain.• By definition a secondary disorder.• Many synonymous terms.• Prominent in other areas of medicine.
– Post-op– chronic medical illness
• Represents risk for significant morbidity and mortality
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DeliriumRelative condition of CNS
CNSInsult
Tx. Of underlying causes
Relative Conditionof CNS
Neuropsychiatric Model of Delirium
Hypo Hyper
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How Do We Make the Diagnosis?
• Arises from sub-cortical brain areas and subsequently affects cortical areas.
• Predominant presentation of confusion and disorientation (sub-cortical predominance)
• Varying levels of alertness/consciousness.• Fluctuating mental status during course.
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DSM IV TR Criteria• Attentional deficit• Disorganized thinking and speech• At least two of the following:
– reduced level of conciousness– perceptual disturbances– sleep-wake cycle disturbances– changes in psychomotor activity– disorientation– memory impairment
• Relatively rapid onset• Evidence or assumption of secondary cause
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Treatment• Identification and correction
of underlying causes if possible.
• Minimize complicating factors.
• Possible low dose high-potency typical or atypical neuroleptics.
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Comparison of Dementia and Delirium
• Dementia– insidious onset– persisting, stable– predominant memory
impairment with mild confusion
– possible contributory reversible causes.
• Delirium– Rapid onset– Varying, fluctuating– predominant confusion
– By definition a reversible cause.
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Summary
• Almost any illness can present with cognitive dysfunction and secondary dysfunction is more likely than primary.
• Dementia as a syndrome or class of diseases increases in prevalence with age.
• Look for cortical symptoms – Dementia• Look for sub-cortical symptoms – Delirium.• Think about the foundations for a solid differential.