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And overview of Cognitive Disorders

Cognitive Disorders:Introduction
 Cognition includes attention, memory, language, orientation, praxis, executive function, judgment, and problem solving.  Broadly it encompass  Delirium  Dementia  Amnesias,  Mild cognitive impairment and  Cognitive disorders due to other medical conditions

 Latin verb deliro—to be crazy  Delirium is characterized by an acute decline in both the level of consciousness and cognition with particular impairment in attention.  A life threatening, yet potentially reversible disorder of the central nervous system (CNS),  Delirium often involves perceptual disturbances, abnormal psychomotor activity, and sleep cycle impairment.  The core symptoms of delirium include a disturbance of consciousness that is accompanied by a change in cognition that develops rapidly, usually hours to days, and tends to fluctuate during the course of the day

Amnesia/ Amnestic Disorders
 Amnesia is specifically “pure” memory deficits  Overall, DSM-IV-TR provides four diagnostic entities under this category:  (1) Amnestic disorder due to cerebral or systemic medical condition,  (2) Substance-induced amnestic disorder,  (3) Amnestic disorder due to unknown etiology, and  (4) Amnestic disorder not otherwise specified.  Korsakoff's Syndrome  In 1889 Serghei Korsakoff described a syndrome of polyneuritis, anterograde amnesia, and confabulations in subjects with chronic alcohol use.

Mild Cognitive Impairment
• Original Criteria • Memory complaint, preferably qualified by an informant • Memory impairment for age and education • Preserved general cognitive function • Intact activities of daily living • Not demented

Dementia : introduction
 Dementia refers to a disease process marked by progressive cognitive impairment in clear consciousness.  According to the DSM-IV-TR dementia is the development of multiple cognitive deficits manifested by both memory impairment and impairment in at least one other cognitive domain including language, praxis, gnosis, and executive functioning.  Dementia also involves multiple cognitive domains, differentiating it from amnestic disorder, which only involves impairment in memory  Another key feature is that the cognitive deficits cause a significant impairment in social or occupational functioning, distinguishing it from mild cognitive impairment, which is also characterized by impairment in memory and/or other cognitive domains, but does not cause significant impairment in functioning.

Dementia : History
 The word dementia derives from the Latin word dementatus, meaning out of one's mind, and, as such, was potentially applicable to any state of psychopathology.  Celsus probably first used the term dementia in the 1st century AD,  In the 4th century AD by Oribasius, physician to the Emperor Julian. wrote of a disease of cerebral atrophy that caused loss of intellectual capacity and weakness of movement.  In 19th century the distinction between cognitive impairment due to dementia was separated from that caused by mental illness by Jean Etienne Dominique Esquirol, as described in his classic work ‘ Mental Maladies: A Treatise on Insanity ’.  Esquirol identified three varieties of dementia: Acute, chronic, and senile.  Senile dementia was defined as a “cerebral affection … characterized by a weakening of the sensibility, understanding and will” and also by marked impairments in memory, reasoning, and attention.  Esquirol also described hallucinations, delusions, aggressive behavior, and motor impairments in patients with dementia.

Dementia : History
 Wilhelm Griesinger In 1845, was the first to describe senile dementia as a disease of the cerebral arteries  Emil Kraeplin, (. Griesinger's students ) narrowed the scope of dementia by differentiating senile dementia from psychoses with cerebral arteriosclerosis, which later came to be known as dementia praecox and, finally, as schizophrenia.  In 1907, Alois Alzheimer was the first to identify specific histopathological changes associated with progressive degenerative dementia.  He described two cases of dementia (in 1907 and 1911) characterized by symptoms of aphasia, apraxia, agnosia, and the histopathological finding of neurofibrillary tangles and milar foci (plaques) that distinguished it from dementia associated with cerebral arteriosclerosis.

 There are many different etiologies for dementia. Neurodegenerative disorders account for the vast majority of dementia cases. The most common is Alzheimer's disease  Dementia with Lewy bodies is characterized by the same neuropathological changes as Alzheimer's disease, neurofibrillary tangles and plaques, plus Lewy bodies in cortical and brainstem regions and accounts for about 15 to 35 percent of dementias.  Vascular disease, both small vessel and large vessel disease affecting cortical or subcortical regions, accounts for about 5 to 20 percent of dementias.

Etiologies of Dementia
1. Neurodegenerative Alzheimer's disease Dementia with Lewy bodies Frontotemporal dementia Parkinson's disease Huntington's disease 2. Vascular Infarction Binswanger's disease Hemodynamic insufficiency 3. Neurological disease Multiple sclerosis Normal-pressure hydrocephalus Brain tumor (primary or metastatic) 4. Endocrine Hypothyroidism Hypercalcemia Hypoglycemia 5. Nutritional Vitamin B12 deficiency Thiamine deficiency Niacin deficiency 6. Infectious Human immunodeficiency disease Prion disease (Creutzfeldt-Jakob disease, bovine spongiform encephalitis, Gerstmann-Straüssler syndrome) Neurosyphilis Cryptococcus 7. Metabolic Hepatic insufficiency Renal insufficiency Wilson's disease Metachromatic leukodystrophy Neuroacanthosis 8. Traumatic Subdural hematoma Dementia pugilistica 9. Exposure Alcohol Heavy metals Irradiation Anticholinergic medications Carbon monoxide

Diagnosis and Clinical Features
 Evaluation History from both the subject and a reliable informant. Onset of cognitive impairment (insidious or sudden), Course (gradual or stepwise, progressive or episodic, or fluctuating), Duration of impairment. An assessment of each cognitive domain is critical. For memory, inquire about short-term, long-term, and remote memory. For language, inquire about word-finding difficulties and remembering names of family members and friends. For praxis, inquire about use of familiar tools or machines, maintenance of previously acquired skills, and dressing or feeding apraxias. For agnosia, inquire about recognition of familiar objects and insight into their condition and limitations. For executive function inquiring involves assessing ability to perform complex tasks or solve problems. The degree of functional impairment should be ascertained. Viz difficulties with job performance,changes in social functioning such as disengagement from usual activities and interests, trouble maintaining social relationships and social roles, and difficulty performing instrumental activities of daily living and, later, activities of daily living. Personality changes may be part of the presentation in frontotemporal dementias. Behavioral disturbances and agitation are common and should be elucidated.

Mini-Mental State Exam
 Mini-Mental State Exam (MMSE). The MMSE is a 30item cognitive test that can be administered in a few minutes to assess orientation, immediate recall, short-term recall, language, and visuospatial function.  This test does not assess praxis, gnosis, or executive function.  Other limitations are that it is not sensitive for detecting cognitive impairment in highly educated patients or in those with high premorbid functioning  A clock drawing task may be readily added to assess executive function

  Nonpharmacological Management Psychosocial Educating patients and families about dementia and the course and what to expect at each stage is important for general treatment and anticipatory planning Maintaining safety, ensuring adequate supervision and support, connecting patients and their families with community supports and resources, Psychotherapy Psychotherapy may be useful in earlier stages of dementia before short-term memory is too impaired. Several forms of therapy have been studied in dementia; the most promising are reminiscence therapy and supportive psychotherapy. Reminiscence therapy allows patients to recall and relive past life events, stimulating memory and mood within the context of their life history. Stimulation-oriented therapies aimed at enhancing pleasurable activities have some support from clinical trials. Examples include recreational therapy (i.e., crafts, games), art therapies (i.e., music, dance, art), pet therapy, multisensory stimulation, simulated presence, aromatherapy, and exercise. Legal and Financial Planning Patients and their families should be encouraged to pursue legal planning such as living wills, power of attorney, and guardianship for when they no longer have the capacity to make decisions for themselves.

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 Pharmacological Treatments  Antipsychotics  The second-generation antipsychotics like risperidone ,olanzapine, quetiapine and aripiprazole are recommonded.  These agents are indicated as first-line treatments in patients with dementia when agitated, aggressive, or psychotic behaviors are present and either the patient's function is impaired or they are endangering themselves or others.  Benzodiazepines  The use of benzodiazepines is largely limited to short-term control of acute agitated behavior with short-acting agents such as lorazepam (Ativan) or oxazepam.

Pharmacological t/t of Alzheimer's Disease
 Cholinesterase Inhibitors  The cholinesterase inhibitors: Tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl).  These agents are reversible inhibitors of the enzyme acetylcholinesterase, which degrades acetylcholine in the synaptic cleft, thereby increasing the availability of intrasynaptic acetylcholine.  Memantine  Memantine is a noncompetitive NMDA receptor antagonist that may modulate excitatory signaling and have neuroprotective actions.  Vitamin E.  Vitamin E is an antioxidant that has been shown to slow nerve damage and delay cell death in animal models and cell cultures. There was some promise for delaying progression of Alzheimer's disease.

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