Delirium Dementia and Other Cognitive Mental Disorders

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					    Delirium, Dementia, and Other
     Cognitive Mental Disorders
Overview and Classification
A. Delirium – an acute, usually reversible
   brain disorder characterized by clouding
   of the consciousness and a reduced ability
   to focus and maintain attention

Types of Delirium
   a. Delirium due to…
b. Substance—intoxication delirium
c. Substance-withdrawal delirium
d. Delirium due to multiple etiologies
e. Delirium not otherwise specified (NOS)

B. Dementia: a chronic, irreversible brain
disorder characterized by impairments of
memory, abstract thinking, and judgment, as
well as changes in personality
1. Chronic development of multiple cognitive deficits
manifested by memory and one or more of the following
cognitive disturbances:

a.Aphasia, a loss of the ability to understand or use

b. Apraxia, an inability to carry out skilled and purposeful
movement; inability to use objects properly

c. Agnosia, an inability to recognize familiar situations,
people, or stimuli

d. Disturbance in executive functioning (i.e., planning,
organizing, sequencing, and abstracting)
Types of dementia (APA, 2000)
 Dementia of the Alzheimer’s type (DAT)
 Vascular dementia (formerly multi-infarct
 Dementia due to other general medical
  conditions .
 Substance-induced persisting dementia .
 Dementia due to multiple etiologies T
 Dementia not otherwise specified (NOS)
Amnestic disorders
 Development of memory impairment characterized by
  inability to learn new information or inability to recall
  previously learned information

 Can be transient (lasting for l month or less) or
  chronic (lasting for more 1 month or less

 Causes     significant impairment in social or
  occupational functioning and sents a significant
  decline from a previous level of functioning
Types of anmestic disorders (APA,
 Anmestic disorder due to . . . (indicate the general
  medical condition)

 Substance-induced persisting amnestic disorder

 Amnestic disorder not otherwise specified (NOS)
Other cognitive disorders (APA, 2000)
 Cognitive dysfunction presumed to be caused by a
  direct physiological effect of a general medical
  condition that does not meet criteria for any of the
  specific delirium, dementia, or arnnestic disorders
  previously listed
 Cognitive disorders not otherwise specified
      a. Mild neurotic disorder
      b. Postconcussional disorder
A. Delirium, dementia, and other cognitive
 disorders are caused by multiple etiologies
 that interfere with cerebral blood flow Q

B. General medical conditions causing an
  interference of necessary blood supply and
  therefore nutrients (e. g., oxygen, glucose,
  vitamins) to the brain can result in cognitive
 Decreased cerebral blood flow: cardiac arrhythmias or arrest,
    shock, hypertension, congestive heart failure, (CHF)
    cerebrovascular attack (CVA), transient ischemic attacks (TIA),
    pulmonary embolism (PE), systemic lupus erythernatosus (SLE)
   Brain hypoxia: chronic obstructive pulmonary disease (COPD),
    asthma, emphysema, anemia, carbon monoxide poisoning
   Vitamin deficiency: alcoholism, pernicious anemia, Wernicke’s
    disease, Korsakoff’s syndrome
   Infections: sepsis, subacute bacterial endocarditis, pneumonia,
    urinary tract infections, AIDS dementia complex (ADC)
    Endocrine and metabolic disorders: uncontrolled diabetes
    mellitus, insulin shock, hypothyroidism, adrenal insufficiency
    electrolyte imbalance, acidosis, alkalosis
   Hepatic and renal failure: hepatic encephalopathy; end-stage
    renal disease
   Trauma and tumors: traumatic brain injury (TBI), carcinomas
 C. Substances causing toxicity to the brain either by
  exposure to, high doses to Pass withdrawal from the
  substance can lead to cognitive disorders
 1. Ingestion of medications such as anticonvulsants,
  neuroleptics, anxiolytics,, the emergency
  antidepressants, cardiovascular medications,
  antineoplastics, and hormones; or exposure to lead,
  aluminum or other heavy metals
 2. Drugs commonly abused such as alcohol, carmabis,
  cocaine, hallucinogens, and anxiolytics, or opioids
 3. Termination or reduction in use of long-term, high-
  dose substances such as alcohol, sedatives, hypnotics,
  or anxiolytics
 D. Genetic or viral diseases can cause pathological changes or
    biochemical imbalances in the brain that interfere with cerebral blood
   1. Dementia of the Alzheimer’s type: specific cause is unknown but
    theories include reduction in brain acetylcholine, accumulation of
    aluminum in the immune system alterations, head trauma, and genetic
    factors such as Down syndrome;
   2. Parkinsons disease: caused by a loss of nerve cells in the substantia
    nigra in the the basal ganglia
   3. Huntington’s disease: transmitted as a mendelian dominant gene,
    and occurs in the areas of the basal ganglia and the cerebral cortex
   4. Pick’s disease: caused by atrophy in the frontal and temporal lobes
    of the brain
   5. Creutzfeldt-Jakob disease: caused by a transmissable virus
III. Assessment
A. Delirium has a sudden onset and an identifiable
1. A positive history for delirium includes: `
 A thorough medical evaluation revealing
   abnormal lab results K
 An electroencephalogram (EEG) confirming
   cerebral dysfunction
 Identification of the underlying cause of delirium
 Ruling out other reasons for delirium (depression,
   anxiety, dementia, or personality disorder)
2. Presenting signs and symptoms _
 Fluctuating levels of consciousness (i.e.,
   alternating periods of coherence with periods of
   confusion); disorientation that worsens at the end
   of the day, usually referred to as sundown
 Alternating patterns of hyperactivity (typical of
   drug withdrawal) to hypoactivity (typical of
   metabolic imbalance)
 Hyperactive behaviors
       l) Rambling, bizarre, incoherent, rapid,
   pressured, or loud speech A
       2) Restlessness, picking at clothes or bed
   linen, irritability, euphoria
Dementia is a progressive disease and symptoms can be
divided into three stages

 Stage l (typically lasts l to 3 years)

   1. Difficulty performing complex tasks related to a
      decline in recent memory; forgetfulness, missed
      appointments; clients often recognize and are
      frightened by their confusion
   2. Declining personal appearance, inappropriate dress for
   3. Lack of spontaneity in verbal and nonverbal
   4. Disoriented to time but can remember people and
      places Decreased concentration, increased
      distractibility impaired judgment
Stage 2 (lasting approximately 2 to l0 years)
   1. Poor impulse control with frequent outbursts and tantrums; labile
      emotions; catastrophic reactions or overreactions to minor stresses
      occur frequently in demented clients
   2. Wandering or aggressive behavior, hallucinations, delusions
   3. Aphasia, which begins with the inability to find words and
      eventually limits the person to as few as six words
   4. Hyperorality, the need to taste, chew, and examine any object
      small enough to be placed in the mouth
   5. Perseveration phenomena, repetitive behaviors such as lip licking,
      finger tapping, pacing, or echolalia
   6. Confabulation, the filling in of memory gaps with imaginary
      information in an attempt to distract others from observing the
   7. Agraphia, the inability to read or write
   8. Agnosia (the inability to recognize familiar situations, people, or
      stimuli) can occur as auditory, visual, or tactile impairments
   9. Alexia, or visual agnosia, is the inability to identify an object or its
      use by sight such as a toothbrush or telephone
Stage 3 (lasting 8 to 10 years before death occurs)
1. Kluver-Bucy syndrome develops, which includes the
     continuation of hyperorality and the development of binge
2.   Hyperetamorphosis, the need to compulsively touch and
     examine every object in the environment
3.   Progressive deterioration in motor ability including
     inability to walk, sit up, or even to smile
4.    Progressive decrease in response to environmental stimuli
     leading to total increasingly confused nonresponsiveness
     or vegetative state
5.   Severe decline in cognitive function, losing ability to
     recognize others
6.   May scream spontaneously or be able to say only one
     word; frequently becomes mute
Planning and Implementation
1. Specific treatment modalities I
   a. Psychopharmacology I
        a. Cholinesterase inhibitors can slow down progression of mild to moderate in
        a. (Cognex) effects can be seen in 6 weeks
        b. Donepezil (Aricept), slows deterioration of mild to moderate
   dementia I
   b. Management of anxiety, aggression, and agitation and has difficulty
        a. Lorazepam (Ativan) 0.5 mg p.o.;
        b. Trazodone (Desyrel) 25 to 500 mg/day; can decrease agitation and ag
                  gression without decreasing cognitive performance I
        c. Buspirone (Buspar) 10 to 60 mg/day; not sedating and has fewer side
                  effects, preferable to benzodiazepines
Management of depression
l) Selective serotonin reuptake inhibitors (SSRIs) are better tolerated in
   older adults than tricyclic antidepressants (TCAs), which have high
   anticholinergic and cardiac side effects
2) Common SSRIs include: fluoxetine (Prozac), paroxetine (Paxil),
   sertraline (Zoloft), and nefazodone (Serzone)

Management of psychotic features (hallucinations and delusions)
 Atypical antipsychotic agents are more effective in managing positive
  and negative symptoms without extra-pyramidal side effects
 Common atypical antipsychotics include: olanzapine (Zyprexa),
  quetiapine (Seroquel), and risperidone (Risperdal)
 Use of haloperidol (Haldol), a potent neuroleptic, is controversial and
  has been known to cause tardive dyskinesia in older adults; small doses
  (0.5 mg) may help to regulate sleep
Behavior modification . .

Use of physical restraints should be carefully evaluated and used as a last
   resort; sensor devices that alert staff when a client is out of bed or
   going outside should be installed to manage risks to safety from
   wandering behavior

Reality orientation in the form of labels on objects in the environment, and
   large print calendars and clocks can be gentle reminders of
   information; discuss meaningful topics such as significant life events,
   family work, or hobbies to promote the person’s identity; avoid
   arguing with or convincing persons with dementia about actual reality;
   communicate in a calm, quiet voice with simple, clear instructions

Group and individual therapies
Reminiscence or life review therapy: facilitate discussion of topics dealing
  with specific life transitions such as childhood, adolescence, marriage,
  childbearing, grandparenthood, and retirement; pets, music, and special
  foods can be used to evoke memories from clients past; share positive
  and negative feelings

Validation therapy: interacting with clients on a topic they initiate, in a
   place and time where they feel most secure; reflecting the underlying
   feelings of concern (e. g., "You miss your husband. You must be
   feeling lonely here. Reality orientation is geared toward the person and
   place rather than to the time

Milieu therapy
   Special care units (SCU): environmentally designed and specifically
   programmed to serve needs of residents with Alzheimers disease and
   related dementias
Design components of SCU

 Safe, secure, specially adapted
 physical environment to accommodate
 wandering behavior inside and outside
 (circular design, secure walkway and
The following interventions should be incorporated into the care of
confused clients:
 Interventions • Provide simple, clear instructions focusing on one task at a
   Speak slowly and in a face-to-face position when communicating with clients
    known to have a hearing loss. Shouting causes distortion of high—pitched
    sounds and can frighten the client.
   Allow the client to have familiar objects around him or her to maintain reality
    orientation and enhance self-worth and dignity.
   `Discuss topics that are meaningful to the client such as significant life events,
    family, work, hobbies, and pets.
   Refrain from arguing or convincing client that delusions are not real.
   Provide a simple, structured environment with consistent personnel to
    minimize confusion and provide a sense of security and stability in the client’s
   Encourage reminiscence and discussion of life review by sharing picture
   Discuss family traditions and holidays, memories of school, courtship, dating
    rituals, favorite pets, and other past events.
   Encourage family/caregivers to express feelings, particularly frustration and
   Provide a list of community resources and support groups available to assist in
    decreasing dice to Pass stress and role strain for the family/caregiver.
   Personalized rooms with own furniture and familiar belongings

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