Dementia and delirium

organic mental health disorder

1. Dementia and delirium Dr. K amal Ghimire

2. Delirium (Acute confusional state) Definition: Acute onset of global but fluctuating cognitive dysfunction, due to an underlying cause. Delirium is more likely to occur in children, when the brain is still developing, and in the elderly, when the brain is starting to degenerate.

3. Clinical features Hypoactive: withdrawn, quiet, sleepy. Hyperactive: restless, agitated and agressive Hallucinations, delusions (often persecutory) Autonomic hyperactivity: sweating, tachycardia and dilated pupils Fluctuating confusion and attention Worse at night- sundowning .

4. Etiology High risk groups: Aged 65 years and over People with diffuse brain disease Current hip fracture Severely ill Pathophysiology Breakdown of blood brain barrier Dopaminergic excess hypercortisolemia

5. Assessment History and examination Investigations: Blood: CBC( exclude anemia, macrocytosis , leukocytosis), ESR, LFT, Glucose, TFT, LFT, Calcium, folate and vitamin B 12, VDRL Urine: Routine and microscopy Chest X ray CT/MRI EEG ( if epilepsy is differential)

6. Management Identify cause and treatment If a patient is distressed or considered a risk to him/herself or others: 1. Short term (<1 week) antipsychotic( eg . Haloperidol) or short acting benzodiazepines ( lorazepam )

7. Preventing delirium

8. Dementia It is acquired, progressive, (usually) irreversible global deterioration of higher cortical function in clear consciousness resulting in impairment of daily activities. Presentation may occur months or years after the onset of symptoms and is often at family instigation because the person frequently has no insight into his or her deterioration. The clinical presentation may vary between different types of dementia.

9. Features and diagnostic requirement

10. Classification

11. Etiology

12. Alzheimer's disease (most common cause) Apolipoprotein E ( ApoE ) gene contributing most to the genetic aetiological component

13. Alzheimer's disease- Clinical features Initial: Gradual memory impairment. Short term/recent memory. Later: Long term memory, apraxia (loss of ability to execute or carry out skilled movements and gestures despite having desire and ability to perform them), visio -spatial impairment, aphasia. Disorientation, bedridden, infection and death.

14. Vascular dementia : stepwise deterioration rather than continuous Pathologically, there is at least one area of cortical infarction. There is a ninefold increase in risk of dementia in the year after a stroke. Vascular risk factors such as hypertension, hypercholesterolaemia , diabetes and smoking are risk factors for both vascular dementia and AD. Dementia with lewy bodies : Dementia with Lewy bodies (DLB) is characterised by fluctuating cognition and alertness, vivid visual hallucinations, spontaneous parkinsonism, sensitivity to neuroleptic medication and a sleep disorder. Frontotemporal dementia: It is characterised by early personality changes and relative intellectual sparing. Normal pressure hydrocephalous: It presents with marked mental slowness, apathy, wide-based gait and urinary incontinence.(wet, wacky, wobbly grandpa.

15. Management Assess History, MSE and rule out the possibility of treatable acute confusional state ( similar investigation as delirium) In Alzheimers disease: cholinesterase inhibitors ( donepezil, rivastigmine , galantamine ), NMDA (glutamate) antagonist: memantine . Treatment of neuropsychiatric symptoms. Social support Cognitive stimulation/ behavioural management techniques.

16. Delirium vs Dementia

17. Thank you