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Cognitive Disorders

I. Nature of Cognitive Disorders

Definition
Cognitive disorders = disorders in which the central feature is the impairment of memory, attention, perception, and thinking.

A. DSM History
Used to be called organic disorders
Denoted dysfunction of the brain Not very descriptive

DSM-IV uses cognitive


Better reflects nature of problems

COGNITIVE DISORDERS
Cognitive disorders (formerly called organic mental syndromes) involve problems in memory, orientation, level of consciousness, and other cognitive functions. a. These difficulties are due to abnormalities in neural chemistry, structure, or physiology originating in the brain, or secondary to systemic illness. b. Patients with cognitive disorders may show psychiatric symptoms secondary to the cognitive problems (e.g., depression, anxiety, paranoia, hallucinations, and delusions). c. The major cognitive disorders are delirium, dementia, and amnestic disorder.

General information

B. Assessment
Mental Status Exam: brief interview used to assess cognitive disorders
5 major components:
1. 2. 3. 4. 5. Appearance and behavior Mood and affect Thought Perception Sensorium and Intellect
Sensorium = consciousness and awareness of surroundings

Cognitive Disorders
II. Types of Cognitive Disorders

A. Delirium
1. Features
Key feature is disturbed consciousness Associated features include:
Clouded sensorium no clear awareness of surroundings Problems with attention Disturbance in memory Incoherent speech Perceptual disturbances (e.g., hallucinations)

A. Delirium (cont.)
2. Statistics and course
Acute onset (within hours or days) and transient course (days to a few weeks)
No life-long delirium

Can be superimposed on another disorder (e.g., dementia)

2. Statistics and course (cont.)


Tends to occur more in certain people:
Elderly Medically ill (e.g., cancer; AIDS) Dementia

A. Delirium (cont.)
3. Causes
Drugs: intoxication, withdrawal, poison
Delirium tremens = tremors and vivid hallucinations of vermin associated with alcohol withdrawal

Medications Infection Head injury Various kinds of brain trauma (e.g., stroke)

A. Delirium (cont.)
4. Treatment
Attending to precipitating problem
Treating medical condition; counteracting effects of substance withdrawal; using antipsychotic meds Recognizing people at risk and paying special attention to those cases to avoid delirium

Prevention is most successful

B. Dementia
1. Features
Key feature is gradual impairment of multiple cognitive abilities including memory, language, and judgment
With impaired social/occupational functioning

Often see global cognitive impairment ability to solve novel problems goes first, then overlearned abilities (e.g., vocabulary) First signs: personality change and memory loss

B. Dementia (cont.)
2. Statistics and course

Incidence is highest in older adults, but can onset at almost any age Not accurate to give one prevalence rate, because it differs by age group:
65-74: 75-84: 85+: 1.29% 3.83% 10.14%

2. Statistics and course (cont.)


Incidence is the same for males and females Onset varies by type of dementia
e.g., Alzheimers vs. vascular dementia

People over age 75 at increased risk for dementia

B. Dementia (cont.)
3. Example: Alzheimers Disease
DSM-IV Criteria A. Development of multiple cognitive deficits manifested by both:
1) Memory impairment 2) One (or more) of the following:
a) b) c) d) Aphasia Apraxia Agnosia Disturbance in executive functioning

DSM-IV criteria (cont.)


B. Significant impairment and decline C. Gradual onset and continuing decline - Rule out other dementias and mental disorders (e.g., Sz)

DEMENTIA
Criteria for severity of Dementia: Mild: Although work or social activities are significantly impaired, the capacity for independent living remains, with adequate personal hygiene and relatively intact judgment. Moderate: Independent living is hazardous, and some degree of supervision is necessary. Severe: Activities of daily living are so impaired that continual supervision is required (e.g., unable to maintain minimal personal hygiene; largely incoherent or mute).
DSM-III-R

3. Alzheimers (cont.)
Onset usually in 60s or 70s
Early signs in 40s and 50s (presenile dementia)

Definitive diagnosis can only be made on autopsy where histopathology confirmed:


1. Gross atrophy of the brain 2. Neurofibrillary tangles 3. Senile plaques

DEMENTIA OF ALZHEIMERS TYPE (ALZHEIMER DISEASE)


Neurophysiological factors a. Decreased activity of acetylcholine (ACh) and reduced brain levels of choline acetyltransferase (i.e., the enzyme needed to synthesize ACh). b. Abnormal processing of amyloid precursor protein. c. Overstimulation of the N-methyl-D-aspartate (NMDA) receptor by glutamate. Gross anatomical changes occur in Alzheimer disease. a. Brain ventricles become enlarged. b. Diffuse atrophy and flattened sulci appear.
General information

B. Dementia (cont.)
4. Causes of dementia
Direct cause linked to type of dementia
Plaques and tangles Alzheimers Blocked artery vascular dementia Multiple genes Alzheimers risk Single dominant gene Huntingtons disease

Genetic factors linked to some dementias


Head trauma is a risk factor (e.g., boxers dementia)

4. Causes (cont.)
Vascular dementia can be influenced by diet as well as genetic factors (link to heart disease) Psychosocial factors
Higher education level is associated with lower dementia risk Social resources and family support can improve life for patients with dementia

NEUROPSYCHIATRIC TREATMENTS
First treat medical problems Second environmental interventions Third neuropsychiatric medications
Cognitive impairment Psychotic symptoms Depressive symptoms Insomnia symptoms Anorexia symptoms Parkinsonian symptoms

B. Dementia (cont.)
5. Treatment of dementia

Limited some drugs can improve cognitive functioning, but only temporary Psychological treatments
Memory wallet Memory skills training Teach to use navigational cues to avoid getting lost

DEMENTIA OF ALZHEIMERS TYPE (ALZHEIMER DISEASE)


Pharmacologic interventions include: Acetylcholinesterase inhibitors [e.g., tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl)j to temporarily slow progression of the disease. These agents cannot restore function already lost. Memantine (Namenda), an NMDA antagonist, was recently approved to slow deterioration in patients with moderate to severe disease. Psychotropic agents are used to treat associated symptoms of anxiety, depression, or psychosis.
General information

Summary
Cognitive disorders involve an impairment of memory, attention, perception, and thinking that represents a change from previous functioning Delirium short-lived; treat precipitating factor (e.g., substance withdrawal) or prevent Dementia gradual, continual decline (e.g., Alzheimers) Dementia treatments are limited; help with memory skills