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ment, the primary task is to rule out delirium
and reversible causes of dementia. The
onset and progression of cognitive decline
provide important clues to the diagnosis.
Patients with Alzheimer s dementia typically
demonstrate a gradual, progressive decline
in cognitive functioning.
D. Vascular dementia shows a more stepwise
decline in functioning where each infarct
causes abrupt impairment. Delirium causes
a sudden onset of mental status changes
with altered level of consciousness and a
rapidly fluctuating course, although the
symptom presentation is similar to dementia.
IV. Treatment
A. Agitated behavior is the most common
reason for admission for patients with de­
mentia or delirium.
B. Alzheimer s disease is treated with
cholinesterase inhibitors for symptomatic
improvement and to possibly slow cognitive
decline.
C. Vascular dementia is treated by reducing
risk factors, such as hypertension,
hyperlipidemia, diabetes, smoking, and
obesity.
D. Atypical antipsychotics are used to treat
delusions, hallucinations, and agitated be­
havior associated with dementia. Delirium
requires treatment of the underlying etiology.
E. Supportive psychotherapy may help pa­
tients and their families to cope with the
stress associated with loss of autonomy,
declining health, and impaired cognitive
functioning.
References, see page 92.
Delirium - History Taking
History of present illness: Assess impaired
consciousness; fluctuating levels of conscious­
ness, arousability, ability to sustain attention,
ability to focus, and reduced clarity of awareness
of the environment. Ask about current symptoms,
nature of onset, causative precipitants, and dura­
tion; delirium develops over a short period of time
and symptoms fluctuate over the course of the
day. Assess cognitive changes, such as, memory
impairment, disorientation, and language distur­
bance.
Ask about abnormalities of mood (eg, anger),
perception (eg, visual hallucinations), and behav­
ior (eg, agitation). Assess psychomotor distur­
bance, such as hyperactivity with increased startle
response, flushing, sweating, tachycardia, nau­
sea, vomiting, and hyperthermia. Hypoactivity may
manifest with slowed reaction time, catatonia, and
depression.
Language disturbance may include rambling,
changes in the flow of speech, or incoherent
speech. Ask about sleep disturbance; insomnia,
nightmares, hypnopompic and hypnagogic halluci­
nations, reversal of the sleep-wake cycle, daytime
drowsiness, and exacerbation of symptoms at
night (ie, sundowning).
Past psychiatric history: Ask about previous
delirious episodes, psychotic symptoms in the
past, and a history of transient cognitive impair­
ments associated with medical illness or surgery.
Substance abuse history: Alcohol intoxication
and withdrawal may cause cognitive impairment,
delirium, amnesia, and psychotic symptoms. Ask
about all substances used, extent of use, and
history of withdrawal symptoms. Alcohol depend­
ence increases the risk of developing delirium.
Social history: Ask about housing, employment,
extent of family support, marital status, and chil­
dren.
Family history: Ask about family history of psy­
chiatric illness and dementia. Delirium does not
occur more frequently among family members
unless the underlying etiology is heritable.
Past medical history: Assess history of seizure
disorder, neoplasm, infection, vascular disease, or
trauma. Ask about cardiovascular disease, liver
disease (hepatic encephalopathy), and renal
disease (uremia).
Medications: Obtain details of medications, with
dosages and duration of treatment. Ask about
over-the-counter medication and alternative
treatments. Toxic levels of anticholinergics,
anticonvulsants, antipsychotics, antihypertensives,
steroids, lithium, and sedatives can cause delir­
ium.
Mental Status Exam
General appearance: Inattentive, limited eye
contact, confused.
Speech: Normal rate, rhythm, and volume.
Mood:  Angry,  afraid.
Affect: Dysphoric, irritable, and labile.
Thought process: Tangential, incoherent, or
irrelevant speech.
Thought content: Paranoid delusions without
systematized content.
Perceptual: Auditory and visual hallucinations are
most common in delirium.
Suicidality: Varies according to the presence of
psychosis and affective symptoms.
Homicidality: May occur in association with
paranoia.
Sensorium/cognition: Not alert, disoriented, with
fluctuating level of consciousness. Impaired
memory and concentration, poor attention and
limited problem-solving abilities.
Impulse control: Limited. Patients may be ag­
gressive with difficulty controlling anger.
Judgment: Impaired. Patients may be inappropri­
ate and disinhibited.
Insight: Fair. Patients realize the nature of their
symptoms.
Reliability: Limited. Attention and thinking are [ Pobierz całość w formacie PDF ]

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