DeliriumDeliriumAmnestic syndromAmnestic syndrom

MUDr.Tomáš KašpárekMUDr.Tomáš Kašpárek

Dep. of PsychiatryDep. of Psychiatry

Masaryk University, BrnoMasaryk University, Brno

DeliriumDelirium

CharacteristicsCharacteristics

transienttransient cognitivecognitive disorder disorder

core featurescore features: impairment of : impairment of consciousnessconsciousness with with attentionattention deficit, deficit, rapid onsetrapid onset, , fluctuating fluctuating coursecourse..

other phenomena may appear more prominent, other phenomena may appear more prominent, but are not always presentbut are not always present– psychomotor changes (agitation), perceptual changes psychomotor changes (agitation), perceptual changes

as illusions and hallucinations, disorganized thought, as illusions and hallucinations, disorganized thought, delusions, disturbances of sleep, emotional changes delusions, disturbances of sleep, emotional changes (irritability, flatness of emotions)...(irritability, flatness of emotions)...

Historical notesHistorical notes

middle ages: phrenitis, frenzy, febrile insanitymiddle ages: phrenitis, frenzy, febrile insanity19th century: 19th century: – „„clouding of consciousnessclouding of consciousness“ – lack of clarity of what “ – lack of clarity of what

it meansit means– „„confusionconfusion“ – lack of specificity to delirium“ – lack of specificity to delirium

„„amencyamency“/acute confusuinal state – terms “/acute confusuinal state – terms describing milder states of delirium, obsoletedescribing milder states of delirium, obsolete50s: 50s: attentionalattentional and other and other cognitivecognitive abnormalities are core features, associated with abnormalities are core features, associated with slowing on the EEGslowing on the EEG

Risk factorsRisk factors

severity of physical illnessseverity of physical illness

older ageolder age

baseline cognitive impairment (dementia)baseline cognitive impairment (dementia)

EtiologyEtiology

manifestation of brain dysfunction due to systemic or manifestation of brain dysfunction due to systemic or brain disease or drug intoxication or withdrawal; often brain disease or drug intoxication or withdrawal; often summation of causessummation of causes– intoxication - anticholinergics, lithium, hypnotics, alcoholintoxication - anticholinergics, lithium, hypnotics, alcohol– withdrawal – hypnotics, alcoholwithdrawal – hypnotics, alcohol– tumortumor– trauma, subdural hematomatrauma, subdural hematoma– infection – cerebral, systemicinfection – cerebral, systemic– cardiovascular – cerebrovascular, cardialcardiovascular – cerebrovascular, cardial– metabolic – hypoxemia, electrolyte disturbances, renal or metabolic – hypoxemia, electrolyte disturbances, renal or

hepatic failure, hyper/hypoglycemiahepatic failure, hyper/hypoglycemia– endocrine – thyriod, glucocorticoid disturbancesendocrine – thyriod, glucocorticoid disturbances– nutritional – thiamin, B12 deficiencynutritional – thiamin, B12 deficiency

DiagnosisDiagnosis

Delirium due to general medical conditionDelirium due to general medical conditionSubstance intoxication deliriumSubstance intoxication deliriumSubstance withdrawal deliriumSubstance withdrawal deliriumDelirium due to multiple etiologiesDelirium due to multiple etiologiesCRITERIACRITERIA– Disturbance of Disturbance of consciousnessconsciousness (reduced clarity of (reduced clarity of

awareness of the environment) with reduced ability to awareness of the environment) with reduced ability to focus, sustain ro shift focus, sustain ro shift attentionattention

– A change in A change in cognitioncognition (memory - recent, language, (memory - recent, language, disorientation) or a disorientation) or a perceptualperceptual disturbance not due to disturbance not due to pre-existing dementiapre-existing dementia

– rapidrapid onset and onset and fluctuatingfluctuating course course

DDifferential diagnosisifferential diagnosis

DementiaDementia– include temporal factor (onset, course, include temporal factor (onset, course,

progression)progression)– no alteration of consciousnessno alteration of consciousness

Psychotic, mood, anxiety disordersPsychotic, mood, anxiety disorders– no alteration of consciousnessno alteration of consciousness

TreatmentTreatment

Treatment of primary medical conditionTreatment of primary medical condition

minimizing doses of all sedative and minimizing doses of all sedative and psychoactive medications (except of alcohol or psychoactive medications (except of alcohol or sedative withdrawal delirium)sedative withdrawal delirium)

symptomatic control of agitationsymptomatic control of agitation– high potency AP (haloperidol)high potency AP (haloperidol)– avoidavoid low potency AP and sedative agents low potency AP and sedative agents

(benzodiazepines, antihistaminics) – (benzodiazepines, antihistaminics) – worseningworsening!!!!!!– severe, life threatening agitation – sedation with severe, life threatening agitation – sedation with

controlled ventilationcontrolled ventilation

Amnestic disordersAmnestic disorders

CharacteristicsCharacteristics

DefinitionDefinition: acquired : acquired impaired ability to impaired ability to learn learn and recall new information (and past and recall new information (and past events sometimes)events sometimes)

No attention deficitNo attention deficit or clouding of consciousness or clouding of consciousness (delirium), (delirium), no other cognitive dysfunction no other cognitive dysfunction (dementia)(dementia)

Secondary syndromes caused by systemic medical or Secondary syndromes caused by systemic medical or primary cerebral diseases, substance abuse disorders, primary cerebral diseases, substance abuse disorders, medical adverse effectsmedical adverse effects

Historical notesHistorical notes

KorsakoffKorsakoff– alcoholic psychosis, ie severe disturbance of mental alcoholic psychosis, ie severe disturbance of mental

statusstatus

DSM III, III-RDSM III, III-R– memory impairment (short, long-term memory)memory impairment (short, long-term memory)

DSM IVDSM IV– key feature = impaired learningkey feature = impaired learning– distinction vs. dementia: dementia = multiple distinction vs. dementia: dementia = multiple

impairmentimpairment– transient vs. chronic forms (breakpoint = 1 month)transient vs. chronic forms (breakpoint = 1 month)

EtiologyEtiology

Diencephalic and middle temporal lobe structures Diencephalic and middle temporal lobe structures (mammillary bodies, hippocampus)(mammillary bodies, hippocampus)Causes of amnestic syndrome:Causes of amnestic syndrome:– closed head traumaclosed head trauma– penetrating missile woundspenetrating missile wounds– focal tumorsfocal tumors– surgical interventionsurgical intervention– herpes simplex encephalitisherpes simplex encephalitis– infarction of the territory of the posterior cerebral arteryinfarction of the territory of the posterior cerebral artery– hypoxiahypoxia– chronic use of alcohol with thiamine deficiencychronic use of alcohol with thiamine deficiency

Transient forms – linked with CVS disorders, pathology Transient forms – linked with CVS disorders, pathology in the vertebrobasilar system, episodic physiologic or in the vertebrobasilar system, episodic physiologic or metabolic disorders, acute intoxications, seizuresmetabolic disorders, acute intoxications, seizures

DiagnosisDiagnosis

Amnestic disorder due to a General Medical Amnestic disorder due to a General Medical ConditionConditionSubstance-induced persisting amnestic disorderSubstance-induced persisting amnestic disorderCRITERIACRITERIA– development of memory impairment as manifested by development of memory impairment as manifested by

impairment in the ability to learn new information or impairment in the ability to learn new information or the inability to recall previously learned informationthe inability to recall previously learned information

– significant impairment in social or occupational significant impairment in social or occupational functioning due to the memory impairmentfunctioning due to the memory impairment

– memory disturbance does not occur exclusively memory disturbance does not occur exclusively during the course of delirium or dementiaduring the course of delirium or dementia

Differential diagnosisDifferential diagnosis

DeliriumDelirium– memory impairment in the context of impaired memory impairment in the context of impaired

consciousnes and reduced ability to sustain, focus ro consciousnes and reduced ability to sustain, focus ro shift attentionshift attention

– but – amnestic disorder may emerge from delirium but – amnestic disorder may emerge from delirium (Korsakoff´s syndrome)(Korsakoff´s syndrome)

DementiaDementia– coexistence of memory impairment with multiple coexistence of memory impairment with multiple

cognitive deficitscognitive deficits

Dissociative amnesiaDissociative amnesia– lack of impaired learning new information – lack of impaired learning new information –

circumscribed inability to recall previously learned circumscribed inability to recall previously learned information with normal functioning in the presentinformation with normal functioning in the present

Clinical notesClinical notes

Transient global amnesiaTransient global amnesia– episodes of transitory inability to learn new information (to form episodes of transitory inability to learn new information (to form

memories)memories)– variable inability to recall memories from the episodevariable inability to recall memories from the episode– restoration to completly intact cognitive staterestoration to completly intact cognitive state– no behavioral changes x may be confusion, perplexityno behavioral changes x may be confusion, perplexity

sudden/gradual onset – according to the cause (head sudden/gradual onset – according to the cause (head trauma, CNS event, chronic toxic exposure)trauma, CNS event, chronic toxic exposure)disorientation – may be to place and time due to severe disorientation – may be to place and time due to severe mnestic disorder x spared orientation to person mnestic disorder x spared orientation to person (dementia)(dementia)lack of insightlack of insightconfabulationsconfabulations

TreatmentTreatment

No effective treatments for amnestic No effective treatments for amnestic disorder aimed specifically at learning disorder aimed specifically at learning deficitdeficit

Treat underlying pathological processTreat underlying pathological process– rehabilitation after brain injuryrehabilitation after brain injury

References :References :

Waldinger R.J.: Psychiatry for medical Waldinger R.J.: Psychiatry for medical students, Washington, DC : American students, Washington, DC : American Psychiatric Press, 1997Psychiatric Press, 1997

Kaplan HI, Sadock BJ, Grebb JA.: Kaplan and Kaplan HI, Sadock BJ, Grebb JA.: Kaplan and Sadock´s synopsis of psychiatry, Baltimore: Sadock´s synopsis of psychiatry, Baltimore: Williams and Wilkins, 1997Williams and Wilkins, 1997