Neurocognitive Disorders and Delirium Quiz

Neurocognitive Disorders

• Neurocognitive disorders is a globally used term that encompass conditions like Delirium and Dementia.
• Previously these were referred to as organic mental syndrome and disorder (DSM-5, 2013).
• Neurocognitive disorders include: Delirium, Dementia, Substance abuse disorders, Intellectual disability, and Epilepsy.

Causes of Cognitive Impairment

• Cognitive psychotic conditions have various causes or etiologies.
• A mnemonic device, "MEND A MIND," helps remember the various causes:
• M - Metabolic disorder
• E - Electrical disorder
• N - Neoplastic disease
• D - Degeneration
• A - Arterial disease
• M - Mechanical disease
• I - Infectious disease
• N - Nutritional disease
• D - Drug toxicity

Delirium

• Definition: An acute organic mental syndrome characterized by a clouding of consciousness.
• Accompanied by disorientation, memory impairment, and a decrease in concentration.
• Delirium is reversible.
• Delirium is prevalent among patients over age 65 admitted to the hospital (up to 15%).
• Risk factors include: Increasing age, underlying dementia and physical illness.
• Full recovery is typical in delirium cases.

Types of Delirium

• Delirium due to a general medical condition
• Substance-induced delirium.
• Substance intoxication delirium
• Substance withdrawal delirium
• Delirium due to multiple etiologies
• Delirium not otherwise specified

Causes of Delirium (Specific examples)

• A. Infections: Systematic infections like malaria, typhoid, and pneumonia.
• B. Drug Intoxication/Withdrawal: Alcohol, anxiolytics, opioids, CNS stimulants, cocaine, crack, amphetamines and marijuana.
• C. Neurological disorders: Seizures and head trauma
• D. Postoperative state, Puerperium (Post Partum): Some drugs like antibiotics, antiparkinsonian, anticholinergics (with special note on antituberculosis), anticonvulsants, analgesics and anti-inflammatory drugs.
• 7) Metals and Gases: Mercury, Lead, Arsenic, Carbon Monoxide.
• Intracranial: conditions like meningitis, encephalitis, and cerebral malaria.

Clinical Features of Delirium

• Altered state of alertness, awareness and consciousness (hyper-alert or obtund; lucid intervals are possible).
• Dramatic or sudden onset; can evolve over days or weeks.
• Disorientation and confusion
• Decreased attention, concentration and memory
• Psychotic symptoms (paranoia and hallucinations—often visual).
• Behavioral disinhibition; emotional liability; irritability.
• Psychomotor retardation or agitation (fluctuating over 24 hours).
• Fragmented sleep/wake cycle; increased agitation at night.
• Usually reversible with underlying etiology corrected.

Common Investigations for Delirium

• Blood HB (hemoglobin), Blood Urea, Electrolytes
• Urinary sugar and protein
• Bender Gestalt Test
• Mental testing for memory
• Fundus Examination
• X-ray of skull
• EEG (electroencephalography)
• CSF (cerebrospinal fluid) routine
• Brain scan
• Brain biopsy

Dementia

• Definition of Dementia: Dementia is characterized by (usually) insidious (but sometimes acute) development of generalized brain dysfunction with multiple cognitive deficits.
• Impairment in cognitive functions leads to disturbances in social and/or occupational functioning, and a decline from previous levels of functioning.
• Awareness and mental alertness are typically intact and stable in the early stages of dementia, in contrast to the unstable level of consciousness seen in delirium.
• Often, but not always, cognitive dysfunction initially presents as memory impairment (learning new information and recalling previously learned information).

Types of Dementia

• Dementia of Alzheimer's type
• Vascular dementia
• Dementia due to HIV
• Dementia due to head trauma
• Dementia due to Parkinson's Disease
• Dementia due to Huntington's Disease
• Dementia due to Rick's disease
• Dementia due to Creutzfeldt-Jakob's Disease
• Dementia due to other general medical conditions
• Substance-induced persisting dementia
• Dementia due to multiple etiology
• Dementia not otherwise specified

Causes of Dementia (partial listing)

• Alcohol-related dementia
• Alzheimer's disease
• Amyotrophic lateral sclerosis
• Bromide poisoning
• Chronic granulomatous meningitis (tuberculosis, fungal)
• Folic acid deficiency
• Head trauma
• Human immunodeficiency virus (HIV)
• Huntington's chorea
• Hypothyroidism
• Multi-infarct dementia
• Multiple sclerosis
• Neoplasms
• Normal-pressure hydrocephalus
• Parkinson's disease
• Postanoxic state
• Progressive Supranuclear Palsy
• Transmissible virus dementia (Jacob-Creutzfeldt disease)
• Vitamin B12 deficiency

Clinical Features of Dementia

-Impairment of intellectual functions.

• Loss of memory (anterograde and retrograde amnesia).
• Episodes of confusion.
• Poor judgment (leading to inappropriate decisions);
• Mood swings and irritability.
• Apathy or childish euphoria, and poor self-care/hygiene (personal care).
• Paranoid ideas and hypochondriac delusions.
• Hallucinations
• Fragmented sleep-wake cycle
• Disorientation, and regression to childishness.

Other Cognitive Impairment Disorders

• Amnestic syndrome - cognitive impairment with no change in consciousness, short-term and long-term memory impairment.
• Organic delusional syndrome - predominant delusion with no change in consciousness, intellectual abilities or mood.
• Organic hallucinations - experiencing hallucinations with no change in consciousness, intellectual functions or mood.
• Organic mood syndrome - change in mental status with manic or depressive episode symptoms.
• Organic anxiety syndrome - Active, recurrent panic attacks or generalised anxiety.
• Organic personality syndrome- Major change in personality style; emotional swings, and a decrease in impulse control.
• Pre-senile dementia- chronic organic mental condition of intellectual and emotional impairment before 65.
• Types of Pre-senile dementia. (e.g. Huntington's chorea, Pick's disease, Alzheimer's disease, Creutzfeldt-Jakob's Disease).

Senile Dementia

• A chronic, organic mental condition.
• Due to brain's degenerative changes often appearing after 65.
• Characterized by lasting impairment symptoms and behavioral changes.

Clinical Features of Senile Dementia

• Psychological features: Feeling rejected, behaving like a child, loss of memory, overtalkativeness
• Physical features: Incontinence, general bodily weakness, weight loss, and blurred vision, Loss of teeth.
• Neglect of personal hygiene, and epileptic fits

Epilepsy

• A brain disorder defined by the recurring excessive neuronal discharges.
• Characterized by transient episodes of motor, sensory, or psychic dysfunction; accompanied by or without unconsciousness or convulsions.
• Marked changes are exhibited in the recorded electrical brain activity.

Causes of Epilepsy

• Constitutional factors (idiopathic)
• Genetic predisposition
• Endocrine disorders, Aging, and Body build (Athletic—old theory)
• Predisposing factors
• Intracranial infections
• Degenerative diseases
• Brain tumours
• Head injuries
• Metabolic disorders (e.g., uraemia, hypoglycemia, eclampsia)
• Emotional stress
• Unknown causes
• Precipitants
• Drugs
• Boredom
• Sensory stimuli
• Fatigue
• Crowds of people
• Sexual activity
• Excitement
• Strong emotions
• Fevers

Types of Epilepsy

• Generalized epilepsy
• Focal/partial epilepsy

Generalized Epilepsy

• With loss of consciousness.
• Abnormal electrical discharges spread throughout the brain.
• Common varieties are grand-mal (major) and petit-mal (minor).

Grand-Mal Epilepsy

• Characterized by distinctive phases:
• Aura (warning phase)—peculiar warning sound
• Tonic phase—prolonged contraction of muscles
• Clonic phase—spasmodic muscle rigidity and relaxation
• Coma phase—complete unconsciousness

Petit-Mal Epilepsy

• A brief loss of consciousness (5-20 seconds)
• Confusion and staring
• Slight twitching of face muscles

Partial or Focal Epilepsy

• Consciousness may be maintained.
• Discharge occurs within a localized area.
• Psychomotor seizures are possible (without convulsions): lasting several seconds, minutes, hours, or days.

Epilepsy-Related Conditions

• Epileptic fugue—confusional state (wandering, violence)
• Epileptic furor—extreme violence and destructive behavior (psychotic)
• Epileptic twilight state—dreamlike, confused, long-lasting episode, restlessness, violence.
• Status epilepticus/serial epileptic—epileptic seizures in quick succession.
• Epileptic dementia—gradual mental decline and deterioration that eventually leads to dementia.

Diagnosis, Investigations, and Prognosis of Epilepsy

• Diagnosis: Chemical features observed, EEG recording of normal impulses in the brain, lumber puncture of CSF for bacteriological examination
• Treatment: Early treatment offers more chance of successful outcomes; psychotic epileptics tend to have worsening cognitive decline/progressive dementia.

Mental Retardation

• Developmental disorder originating before age 18, resulting in impaired adaptive behavior, typically associated with decreased intelligence and learning disabilities.
• Onset before 18 years
• Causes
• Genetic factors (abnormal genes)
• Environmental factors (e.g. infections like Rubella during pregnancy)
• Chemical exposure, malnutrition, premature birth.
• Severity is based on IQ scores (Mild, Moderate, Severe, Profound).
• Characterizations
• Developmental delays (sitting, standing, walking, talking)
• Physical abnormalities (physical stigmata—eg., a. The Cranium (excessively large/small), b. The Mouth (malformations like high palate, c. The Ear (irregular shape), d. Eyes (slanted/abnormal), e. The Trunk (long trunk), f. Hand and Fee.

Substance Abuse/Alcoholism

• Characterized by excessive consumption of an agent, impacting biological, psychological and socio-cultural integrity.

• Includes taking drugs or alcohol outside prescribed guidelines

• Causes Strains/stress, Peer group influence, Poor upbringing, Anxiety, Heredity, low self-esteem, Certain occupations (breweries, mortuary, some medical professionals. Occupational, Curiosity.

• Effects Acute/chronic intoxication, resulting in physical and mental illness and interference with socio-economic functioning and interpersonal relationships.

• Types

• Alcoholism—excessive and prolonged alcohol intake

• Drug dependence (Addiction)—periodic/chronic intoxication.

• Causes = Hereditary and Familiar factors, Anxiety, Peer group influence, Psychological/mental illness, Chronic physical illnesses, Medical involvement of a professional or in certain occupations, Curiosity.

• Examples of drugs = Marijuana, Cocaine, Heroin, Mescaline, Lysergic Acid Diethylamide (LSD), Amphetamine, Barbiturates, Morphine

• Withdrawal Syndrome = Sudden cessation of intake following chronic use (alcohol, amphetamines, etc)

• Characterizations

• Compulsive and repeated abuse despite adverse effects—psychoactive drugs.

• Chemical/physical dependency—use of a substance to prevent withdrawal symptoms leading to craving, tolerance, addiction, and habituation.

• Diagnosis = Individual characteristics, Blood/urine screening, breathalyzer, etc.

Other Alcohol-Related Conditions

• Delirium Tremens (Alcohol Withdrawal Delirium) : Psychiatric condition characterized by signs and symptoms due to sudden alcohol withdrawal.

• Alcoholic Hallucinosis: Auditory hallucinations, usually 2-4 days after heavy drinking

• Korsakoff's Psychosis: Psychiatric disorder in alcoholism, often linked to thiamine deficiency/nutritional deficiency.

• Consequences of Chronic Alcoholism - Physical/psychological problems manifestation in clinical manifestations, such as neglect, disorientation, confusion; mood swings, hallucinations and delusions, suicidal tendencies, and in serious cases, liver cirrhosis and, tremors, and possible death.

• Management of alcoholism—Hospitalization, Close observation/safety procedures, Complete bed rest, Prescribed medication( tranquilizers), Nutrition/fluids+vitamins, Attention to personal hygiene, Psychotherapy/support groups (AA), Occupational/job-seeking therapy, Rehabilitation.

Test your knowledge on senile dementia and its symptoms, risk factors, and how it differs from delirium. Explore common features associated with neurocognitive disorders and challenging aspects of cognitive impairment. Dive deep into the clinical features and classifications to enhance your understanding.