DELIRIUM, DEMENTIA AND

OTHER COGNITIVE
DISORDERS
Dr. Loraine Barnaby
Consultant Psychiatrist
 NOTE
• The presentation comprises separate
PowerPoint presentations on
• Delirium
• Dementia
• Delirium vs. depression
• A short video on Alzheimer’s disease
• And a Word document which was taken from an
internet site.
• All are currently available on the computer (2nd
from left) in the library in the desktop folder
named “Barnaby”
 OBJECTIVES DELIRIUM,
DEMENTIA
By the end of the session, students will be able
to;
• Define delirium, dementia, pseudodementia.
• State the essential clinical features
• Differentiate between each
• List causes of each condition
• Justify the investigations that should be
conducted.
 continued
• Differentiate between a regular mental status exam
(MSE) and Folstein’s Mini Mental State Exam (MMSE)
• Carry out a MMSE
• Carry out the Clock-drawing test.
• Apply the information gained from history and
investigation to arriving at a diagnosis
• List the principles of management of each condition
• Name the drugs used for cholinergic enhancement in
Dementia and their mode of action
 continued
• Define Wericke’s encephalopathy and
Korsakoff’s Psychosis
• Discuss the essential features and
possible causative factors in each
condition.
• List the steps in Management
 continued
• Via discussion, demonstrate an
understanding of the appropriate
approach to a person who is delirious
• Via discussion, demonstrate an
understanding of the appropriate
approach to a person who has dementia.
 DELIRIUM definitions
From Sadock and Sadock

• Disturbance of conscious with reduced ability to

focus, sustain or shift attention
• Change in cognition or development of
perceptual disturbance that is not better
accounted for by a pre-existing, established or
evolving dementia
• Disturbance develops over a short period of time
(hours to days) with a fluctuating course over the
course of the day.
• Evidence from history, physical exam, or lab
findings that the disturbance is caused by the
direct physiological consequences of a general
medical condition.
 DELIRIUM
• Disturbance of conscious with reduced ability to focus,
sustain or shift attention
• Change in cognition or development of perceptual
disturbance that is not better accounted for by a pre-
existing, established or evolving dementia
• Disturbance develops over a short period of time (hours
to days) with a fluctuating course over the course of the
day.
• Evidence from history, physical exam, or lab findings that
the disturbance is caused by the direct physiological
consequences of a general medical condition.
 Types of delirium
• 1. Delirium due to general medical condition
• 2. Delirium due to substance intoxication
• 3. delirium due to substance withdrawal
• 4. delirium due to multiple aetiologies (DSM IV)
 Characteristics of Delirium
• Somnolent or hypoactive type
• Activated or hyperactive type – greater
tendency to have hallucinations and
delusions (Ross et al 1991)
 Some causes of Delirium
• Some delirium is secondary to life threatening
conditions- e.g. those causing acute cerebral
ischaemia or hypoxia
• CNS infections- meningitis, encephalitis, abscess
• Intracranial haemorrhage or infarction
• Acute intoxication- anticholinergic drugs, CNS
depressants, stimulants
 Causes cont’d
• Hypo and hyperglycemia +/-
ketoacidosis
• Acid-base/ electrolyte imbalance
• Thyroid storm
• Hypertensive encephalopathy
 EPIDEMIOLOGY
• 15% of elderly people in medical or
surgical wards

• Higher in nursing homes

• Risk factors include age, previous brain

damage, dementia, visual impairment,
malnutrition, dehydration, severe illness,
multiple medications, bladder
catheterization, urinary infections,
iatrogenic causes
 Investigations
• CBC- Hb, MCV; WBC & Diff; ESR;
• Chemistry-Electrolytes; BUN, CREATININE; Glucose;
calcium; albumin; ammonia;
• Liver function tests
• Toxicology screen; medication levels
• Arterial blood gases
• Urinalysis, including acetone and glucose
• CXR
• ECG

• ADDITIONALLY IF INDICATED, heavy metals, B12,

thiamine, folate, thyroid function, Collagen vascular
screen, LE prep, ANF, urinary porphobilinogen,
lumbar puncture, CT, MRI, EEG
 MENTAL EXAMINATION
• Regular MSE not so useful
• Confusion Assessment Method CAM
(Inouye 1990) assesses the following:
1. Acute onset, fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
 DELIRIUM RATING SCALE
Trzepacz et al 1988, 1995
• 1. Temporal onset of symptoms
• 2. Perceptual disturbances
• 3. Hallucination type
• 4. Delusions
• 5. Psychomotor behaviour
• 6. Cognitive status during formal
testing
• 7. Physical disorder
• 8. Sleep-wake cycle disturbance
• 9. Lability of mood
• 10. Variability of symptoms
 CLOCK-DRAWING TEST

• Patient presented with a paper on which a

blank circle about 10 cm diameter is
drawn, representing the clock face.
• Patient asked to put the numbers on the clock
• Patient asked to depict the time 11.10 or
8.20 on the clock.
• Test reviewed and scored.
• Not culturally biased, sensitivity and
specificity said to be satisfactory.
 Differential diagnosis
• Dementia
• Psychosis, delirious mania, hypomania,
depression, catatonic excitement,
hysteria
• Drugs with central anticholinergic
effects
and Pseudodelirium
 DELIRIUM VS DEMENTIA
(General)
• Temporal history
• Clouding of consciousness, changing
levels of consciousness and attention
• Quality of Perceptual abnormalities
• Sleep-wake disturbances
 DELIRIUM vs DEMENTIA 1
(FROM POCKET HANDBOOK OF CLIN. PSYCH. PAGE 29)

1. History: Acute disease

Chronic disease

2. Onset: Rapid
Insidious (usually)

3. Duration: Days-weeks
Months-years

4. Course: Fluctuating
Chronically

progressive
 DELIRIUM vs DEMENTIA 2
FROM POCKET HANDBOOK OF CLIN. PSYCH. PAGE 29

5. Level of consciousness Fluctuating

Normal

6. Orientation: Impaired, at Intact

initially
least periodically

7. Affect: Anxious, irritable Labile but

not usually anxious

8. Thinking: Often disordered

Decreased amount
 DELIRIUM vs DEMENTIA 3
FROM POCKET HANDBOOK OF CLIN. PSYCH. PAGE 29

9. Memory: Recent memory is Both

recent and

markedly impaired remote are

impaired

0. Perception: Hallucinations
Hallucinations

common less
common

(especially visual) (except

sundownlng)
 DELIRIUM vs DEMENTIA 4
FROM POCKET HANDBOOK OF CLIN. PSYCH. PAGE 29

12. Sleep: Disrupted sleep-wake cycle Less

disruption of
sleep-
wake cycle

13. Attention & Prominently impaired Less

impaired
awareness

14. Reversibility Often reversible Majority not

reversible
 Treatment
• Identify treatable cause and treat it

• Benzodiazepines for alcohol, benzodiazepine and

barbiturate withdrawal

• Lorazepam recommended for the elderly

because it has no active metabolites and is
conjugated
by the liver in one step. This conjugation is not
affected
by liver disease.
 Treatment

• Central anticholinergics treated by reassurance

and
physostigmine, a centrally acting
cholinesterase
inhibitor, with short action

• Haloperidol for agitation

• Haloperidol & lorazepam used for refractory

states.
DEMENTIA
 DEFINITION
DEMENTIA:
• 1.GLOBAL IMPAIRMENT OF MENTAL
FUNCTION WHICH FOLLOWS A CHRONIC
AND PROGRESSIVE COURSE.
• 2.“The deterioration of intellectual capabilities,
memory, judgment, and personality to the extent
that daily functioning and the quality of life are
seriously impaired.”
(Source: Pasternack, J. University of Waterloo,
Ontario, Canada. ‘An Introduction to Molecular Genetics.’
 CAUSES
PROGRESSIVE CEREBRAL
DEGENERATION DUE TO:
• Alzheimer’s Disease
• Vascular Dementia
• Dementia with Lewy Bodies
• Mixed vascular/Alzheimer
• Other
Functional Activities Questionnaire
(FAQ)
Functional Activities Questionnaire
(FAQ)
Comparison of Normal and Abnormal
brains
Characteristic autopsy signs of
Alzheimer’s disease
 Other causes
• Pick’s disease
• Creutzfeld- Jakob disease
• Huntington’s Chorea
• Down’s syndrome
• Alcohol
• Tumour
• Dementia pugilistica
• Haematoma
 OTHER CAUSES
• Infections- encephalitis, abscess,
meningitis, HIV, GPI
• Parkinson’s
• Chronic epilepsy
• Metabolic
• Endocrine
• Vitamin deficiency
• Toxins(lead, arsenic etc.)
 SYMPTOMS
• MEMORY ASSOCIATED

• THINKING ASSOCIATED

• BEHAVIOURAL
 DIAGNOSIS
• Careful history- patient AND family
• Thorough physical examination
• Detailed neurological examination
• Laboratory tests- routine & special
• Brain imaging CT and MRI
• Mini Mental Status Examination MMSE
• Mental Status Examination MSE
MINI MENTAL STATUS EXAMINATION
MMSE (FOLSTEIN)

VARIOUS ASPECTS OF MEMORY &

COGNITION
• ORIENTATION
• REGISTRATION
• ATTENTION & CALCULATION
• RECALL
• LANGUAGE
• CONSTRUCTION
 MMSE 1
• Orientation
What is the (year-1) (season-1) (date-1) (day-1) (month-
1)?
(5 points
possible)
Where are we: (state-1) (county-1) (city-1) (hospital or
clinic-1) (floor-1)?
(5 points
possible)
• Registration
Name three objects: 1 second to say each. Ask the
patient for all three after you have said them.
Give 1 point for each correct answer. (3 points)
Repeat until all three are learned. Count trials and record
 MMSE 2
• Attention and calculation
Serial sevens backward from 100 (stop after five
answers). Alternatively, spell WORLD backward.
(5 points)
• Recall
Ask for the three objects repeated above.
One point for each correct answer. (3
points)
• Language and praxis
Show a pencil and a watch and ask subject to name
them.
(2
points)
Ask the patient to repeat the following: “No ifs, ands, or
buts.”
(1
 MMSE 3
• (Three-stage command)
“Take this paper in your right
hand, fold it in half, and put
it on the floor.”
(3 points)

Read and obey the

following: “Close your
eyes.” (1 point)
Write a sentence. (1 point)

Copy this design (interlocking

pentagons).

(1 point)
 MMSE 4
• Maximum score (30 points) • (maximum = 30)
• A score of between 25 and • Mild dementia=20-24
30 on the Mini-Mental State • Moderate
examination is considered
normal in older adults; dementia=11-19
• Severe dementia= 0-
• a score between 18 and 24 10
reflects mild impairment;

• and a score of less than 18,

moderate to severe
impairment;

• Less than 10 is severe

impairment
 GERIATRIC DEPRESSION
SCALE
• A 15-ITEM SCALE* (YESAVAGE, J. in
Psychopharm Bulletin 1988; 24: 709-711

• A score >5 = probable depression.

• *There is an 8-item scale also

 PSEUDO-DEMENTIA
• MEDICAL CAUSES OF DEPRESSION IN
OLDER ADULTS
• CNS- DEMENTIA, PARKINSON’S,
STROKE, HUNTINGTON’S CHOREA
• ENDOCRINE- Hypo & hyper thyroidism,
hypo &hyper parathyroidism
• NEOPLASMS- Visceral Malignancies,
Lymphoma, CNS tumours
 Functional Activities Questionnaire
•
(FAQ)
Informant's Name. Patient's Name _ Date______
INSTRUCTIONS:
• Place a check mark under the column that best describes the patient's
ability to perform the tasks listed below.
•
Normal performance, or has never done task, but informant feels
patient could do so now(0 points)
• Has difficulty but accomplishes task, or has never done task;
however,informant feels patient could accomplish it, but with
difficulty (1 point)
• Requires assistance (2 points)
• Completely unable to perform task(3 points)
1. Writing checks, paying bills, balancing a checkbook
• 2. Assembling tax records, business affairs, or papers
• 3. Shopping alone for clothes,
• household necessities, or groceries '
• 4. Playing a game of skill, working on a hobby

•Adapted and reprinted with permission from J Gerontol. 1982:37:323-329.

Functional Activities Questionnaire (FAQ) cont’d

5. Heating water, making a cup of coffee, turning off the stove

6. Preparing a balanced meal

7. Keeping track of current events
8. Paying attention to, understanding, discussing a TV show,
book, or
magazine

9. Remembering appointments, family occasions, holidays,

medications

10. Traveling out of the neighborhood, driving, arranging to take

buses
POINTS
MEDICATIONS WHICH MAY INDUCE
DEPRESSION

• Benzodiazepines, typical antipsychotics

• Methyldopa, reserpine, propranalol,

clonidine, guanetidine

• Others- Cimetidine, Ranitidine,

Metoclopromide, digitalis preparations,
steroids, Baclofen, sulphonamides
WHY BOTHER TO FIND CAUSE?
• To be able to identify the specific condition
and determine prognosis
• To treat that which is treatable surgically
• To give specific medication to slow
progress of the disease- e.g. in
Alzheimer’s
• To help patient and family in their life
planning.
 PREVENTION
• Lifestyle – exercise, positive
reinforcement
• Diet- vits, low fat, low cholesterol.
• Certain N-SAIDS said to be helpful.

• But can you change your

genes?
 POTENTIALLY REVERSIBLE
CAUSES OF DEMENTIA 1
Neoplasms
• Gliomas
• Meningiomas
• Metastatic tumors, carcinoma,
lymphoma, leukemia
• Remote effects of carcinomas

• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he modified from: Terry RD.
Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 POTENTIALLY
REVERSIBLE
2
Metabolic Disorders
• Thyroid disease (hyper- and
hypothyroidism)
• Hypoglycemia
• Hypernatremia and hyponatremia
• Hypercalcemia
• Renal failure
• Hepatic failure
• Cushing's disease
• Addison's disease ' Hypopituitarism
• Wilson's disease
• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he
modified from: Terry RD. Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 POTENTIALLY REVERSIBLE 3
Trauma
• Craniocerebral trauma
• Acute and chronic subdural haematoma

Toxins
• Alcoholism
• Heavy metals (lead, manganese, mercury,
arsenic) Organic poisons, including solvents and
insecticides
• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he modified from: Terry RD.
Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 POTENTIALLY REVERSIBLE 4
Infection
• Bacterial meningitis and encephalitis
• Parasitic meningitis and encephalitis
• Fungal meningitis and encephalitis
• Cryptococcal meningitis
• Viral meningitis and encephalitis
• Brain abscess
• Neurosyphilis: meningovascular, tabes dorsalis, general
paresis
• Primary AIDS encephalopathy
• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he modified from: Terry RD.
Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 POTENTIALLY REVERSIBLE
5
Autoimmune Disorders
• Central nervous system vasculitis,
temporal arteritis
• Disseminated lupus erythematosus
• Multiple sclerosis

• In Diagnosis and Management of Alzheimer’s Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he modified from: Terry RD.
Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 POTENTIALLY REVERSIBLE 6
Drugs
• Antidepressants
• Antianxiety agents
• Hypnotics
• Sedatives
• Antiarrhythmics
• Antihypertensives
• Anticonvulsants
• Cardiac medications, including digitalis
• Drugs with anticholinergic effects
• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he modified from: Terry RD.
Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 POTENTIALLY REVERSIBLE 7
Nutritional Disorders
• Thiamine deficiency (Wernicke's
encephalopathy and Wernicke-Korsakoff
syndrome)

• Vitamin B12 deficiency (pernicious anemia)

• Folate deficiency

• Vitamin B6 deficiency (pellagra)

• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he modified from: Terry
RD. Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 POTENTIALLY REVERSIBLE 8
Psychiatric Disorders
• Depression
• Schizophrenia
• Mania
• Other psychoses

• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he modified from: Terry RD.
Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
POTENTIALLY REVERSIBLE 9
Other Disorders
• Normal-pressure
hydrocephalus
• Whipple's disease
• Sarcoidosis
• Sleep apnea

• In Diagnosis and Management of Alzheimers Disease and other Dementias by Robert C. Green, MD. MPH p 46-7; as he
modified from: Terry RD. Aging and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 IRREVERSIBLE CAUSES OF
DEMENTIA 1
Degenerative Diseases
• Alzheimer's disease
• Frontotemporal dementias
• Huntington's disease
• Progressive supranuclear palsy
• Parkinson's disease
• Diffuse Lewy body disease
• Olivopontocerebellar atrophy
• In Diagnosis and Management of Alzheimer’s Disease and other Dementias by Robert C. Green, MD. MPH p48; as he modified from: Terry RD. Aging and the
Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 IRREVERSIBLE CAUSES OF
DEMENTIA
• Amyotrophic lateral
scJerosis/parkinsonism-dementia complex
• Hallervorden-Spatz disease
• Kufs disease
• Wilson's disease (if not treated early enough
• Metachromatic leukodystrophy
• Adrenoleukodystrophy

• In Diagnosis and Management of Alzheimer’s Disease and other Dementias by Robert C. Green, MD. MPH p48; as he modified from: Terry RD. Aging and the Brain.
New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 IRREVERSIBLE CAUSES OF
DEMENTIA
Vascular Dementias
• Multiple small or large infarcts
• Binswanger's disease
• Cerebral embolism
• Arteritis
• Anoxia secondary to cardiac arrest, cardiac
failure, or carbon monoxide intoxication

• In Diagnosis and Management of Alzheimer’s Disease and other Dementias by Robert C. Green, MD. MPH p48; as he modified from: Terry RD. Aging and the Brain.
New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 IRREVERSIBLE CAUSES OF
DEMENTIA
• Traumatic Dementia
• Craniocerebral injury
• Dementia pugilistica

• In Diagnosis and Management of Alzheimer’s Disease and other Dementias by Robert C. Green, MD. MPH p48; as he modified from: Terry RD. Aging
and the Brain. New York, NY: Lippincott-Raven Publishers; 1988:17-82.
 IRREVERSIBLE CAUSES OF
DEMENTIA
Infections
• Creutzfeldt-Jakob disease (subacute
spongiform encephalopathy)

• Progressive multifocal leukoencephalopathy

• Postencephalitic dementia

• In Diagnosis and Management of Alzheimer’s Disease and other

Dementias by Robert C. Green, MD. MPH p48; as he modified from: Terry
RD. Aging and the Brain. New York, NY: Lippincott-Raven Publishers;
1988:17-82.
 IRREVERSIBLE CAUSES OF
DEMENTIA
Genetic
Huntington's disease- autosomal dominant
(Chr 4)
characterized by
• Memory deficits, impaired visuospatial
skills; personality and conduct
changes;
depression, anxiety, psychosis
• Chorea
• Dementia
 AMNESTIC STATES
• Wernicke’s Encephalopathy-
mammillary bodies, dorsomedial
nucleus of the thalamus

• Korsakoff’s Psychosis- Similar

pathology
B1 deficiency- Malnutrition, Chronic
Alcoholism
 WERNICKE’S
• GAZE PALSIES
• NYSTAGMUS
• OPTHALMOPLEGIA (especially of the
ABDUCENS NERVE VI)
• GAIT ATAXIA
• CONFUSION
• SHORT-TERM MEMORY LOSS.
 KORSAKOFF’S
• amnesia (severe anterograde
retrograde)

• confabulation.
 TREATMENT
• Fluids
• Thiamine in high doses

Recovery slow.
THANK YOU