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SIWOUCNAS NIVED SINVSEO
S DELIRIUM
CLINICAL FEATURES - 4
Sleep-wakefulness cycle
C insomnia,
C reversal of the sleep -wake cycle,
i daytime drowsiness,
C nocturnal worsening of symptoms,
C disturbed dreams, nightmares
DELIRIUM
CLINICAL FEATURES -5
Mood disturbances
C Dysphoria
CO Anxiety or fear
C Irritability
O Perplexi
0 Euphoria
DELIRIUM
CAUSES
O METABOLIC
O ENDOCRINE
O pruss
CO NUTITIONAL DEFICIENCIES
O SYSTEMIC INFECTIONS
O INTRACRANIAL CAUSES
O] MISCELLANOUS
DELIRIUM
CAUSES
Intra cra
Post epileptic confusion
Trauma ~ concussion
Vascular, neoplasms
Infections - meningitis
Extra cranial
Anticholinergic,
anticonsulvants,
antipakinsonian,
antipsychotics
Endocrine
hypofunction or hyper func
pitituary, adrenals, thyroi
nN Pancreas,
Liver - Hepatic failure
Kidney - Renal failure
Lungs - Carbon dioxide narco:
Cardiac - Cardiac failure, arrhythmias
Deficiency diseases
Thiamine, B 12, Nicotine acid
Post operative
DELIRIUM
Investigations
a CBC SADVIS
ALY NE AINO OMHVANE = INVAN AAAS
amavanr
SaDVLS. N
LVI NIAINO TUAW OISNIHAYAWOD
amuvanr
SAOVIS
aLV1- SLOWR
‘arirvaw amarvawt
= LNA Indo
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SADVLS ALVI
NI agnosia GAMIALSIG — NOLLVLNARIO
‘IVON aRUIVANT SSINSAOIDSNOD
smanLvad
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aTaISATARNN
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IMPAIRED
ATTENTION IMPAIRED USUALLY
NORMAL
DIURNAL, MARKED USUALLY ABSENT
VARIATION (SUNDOWNING)
PERCEPTIONS — VISUAL USUALLY ABSENT
HALLUCINATION HALLUCINATION
S& {ILLUSIONS — S MAY OCCUR
OTHERS ASTERIXIS, CATASTROPHIC
MYOCLONUS REACTION,
Dementia
No Complains about
Cognitive impairments
Emphasizes
achievements
Appears unconcerned
Affect labile
Mistakes on
examination
Recent memory
impaired
Confabulation +
Test poor performance
H/o depression
‘uncommon
PERSEVERATION
Prendo-dementia
(Depression)
Complains about
cognitive impairments
Emphasizes disability earn
Chea Site of lesion Cortex(frontal,
Affect depressed tempro-paricto-
“don’t know” answers occipital &
hypocampus)
Recent memory -N eg Alzheimer’s, Picks
Confabulation absent Severity Severe
‘Test performance
variable Motor Usually normal
WO depression + symptoms
Sub-cortical
Subcortical grey matter
(thalamus, basal
ganglia,rostral brain
stem)
Huntington's,
Parkinsonism
Mild to moderate
dysarthri sana 4q
soma q_— apa padyay qjeaay apap
Strensed padiay q1e393 epesdy — Aroulayy,
sesouse ‘eysiyde
eyuew pee a4aaas ‘woumMmodUn
Stourutos woyssaadaq, uopssoadogy UO Psychotherapy
Psychotherapy is the treatment by psychological means, of
problemas of an emotional nature, in which a trained therapist,
deliberately establishes a professional relationship with a
patient /elient to:
-Remove modify or retard existing symptoms
“Mediate disturbed patterns of behavior
+ to promote positive personality growth
Psychoanalysis & Psvchoanalytical psvchotheray
"Classical Psychoanalysis
=Psychoanalytical psychotherapy
Classical psychoanalysis (Freudian)
#3-S visits per week by the patient
Duration of treatment 3 - 5 years or longer
No history taking
No diagnosis,
‘Free association
=Challenge of defenses & interpretation of resistance
athe patient lies on a couch
Psychoanalytical psychotherapy
=More direct approach
"Duration is briefer & advice is given occasionally
«Therapist & patient sit face to face
Psychological mindedness required
Behavioral thera;
= Therapy based on the theories of learning & aims at chang’
maladaptive behaviors & substituting it with adaptive beh:
"Based on the operant conditioning model of Skinner & the
iors
Mini mental status
‘Orientation
Time (day, date, month, year, season)
lace (country, town, area, hospital, floor)
Immediate recall 3 objects
Attention & calculation (serial 7’s or spell
word backward) (100-7 till 65)
# words or objects named before Q2
Language
Confrontation naming: wateh, pen
Repetition: ‘no ifs, ands, or buts”
Comprehension
Read & perform a command ‘Close your
eyes
a sentence
‘onstruction; copy a design
Total score (out of 30)
“Pick up the paper in your
right hand, fold it in half 7 set it on the floor”
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Surepowe
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TORUS T BUSES Toy MUTOTPUOT THEI
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aiqeatsopun
stynq juesvad spay waned ayy yrs uy suo ;puose
Adesamg worsiaay
uonezssuosap apvuiaysign
uoponasuos Aypsesoye
vopUNUys
ad}oA Jo wontqryu feo0.AdPo4 Ho pasege
uonwzpysuosap speuraysis
(soouanbasue /to}seyag /sitiapas9uV) Save
auop s} siséyeue jeso}avyoge
soos §-9 Uoneanp yz04Ge
aaqy9ay9 ys0e
Advzamp aoaeyag, Abreaction
“Brings to conscious awareness unconscious conflicts &
associated emotions
5% solution of sodium amobarbital or thiopentone ( 500 mg
dissolved in 10 ml normal saline at 1 cc / min.)
=£50-350 mg (3-7 cc) is sufficient elderly 75 mg of amytal
«Indications — hysteria, mute patients catatonic stupor diagnosis
»Contraindication URTI renal or hepatic disease, Porphy’
psychosis
Relaxation therapies
“Jacobsen progressive muscular relaxation
aHypuosis
"TM (Transcendental meditation)
= Yoga
» Vipasana
Biofeed back
Feed back to the patient about his psychological activities —
pulse , respiration, blood pressure
=Relaxometer
Used for Tension headaches, Hypertension
VASCULAR DEMENTIA
DMulfiple cerebral vascular disease
Smal! & medium sized cerebral vessels undergo infarction
producing parenchymal lesion over wide areas of the brain
DOculsion of vessels by arterio plaques or thromboemoli trom
distant origin such as heart valves
VASCULAR DEMENTIA
CCommonest second cause of dementia
One of the treatable causes of dementia
More common in India than other types
VASCULAR DEMENTIA
DaAcute onset
step adder pattern (repeated in
deterioration)
DiFluetuating course
Cypertension, cardio-vascular disease, stroke THA
ological signs
Emotional lability
ion leads to further
VASCULAR DEMENTIA
COCOMMON IN MEN
COWITH HYPERTENSION & CARDIOVASCULAR RISK
FACTORS
COMEDICAL EXAM- CAROTID BRUITS, FUNDUSCOPIC
ABNORMALITIES OR ENLARGED CHAMBERS
Binswauger's disease
al arteriosclerotic encephalopathy
Cismall infaretions of white matter but sparing of the cortical
regions
CMRI reveals the condition &
now more commonly detected
LEWY BODY DEMENTIA 10> wa
S>fBDUY PIN > POO} 1007]
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28H [EPPINS PIAA]
NOISSAMAAT NITATS AOLVIN
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INGARIV dT FATIINSOD CT *Clase monitoring 6 monthly
DEMENTIA
DSM-IV
Multiple cognitive deficits (at least one)-
mAphasia
Apraxia
mAgnosia
Disturbance of executive functioning
Severe to cause occupational or social functioning
ODecline from the previous fevel of functioning
OExclude delirium:
OE gical cause of the Dementia
DEMENTIA
LINICAL, FEATURE:
COMEMORY IMPAIRMENT
COCOGNITIVE DISTURBANCES
BAphasia Ganguage )
WApraxia (motor )
|Agnosia (object identification)
WAbstract thinking
CIPERSONALITY CHANGE
DEMENTIA
CLINICAL FEATURES «1
MEMORY IMPAIRMENT
"Recent memory worse than remote memory disturbance (inability to
recall 3 objects ater 5 mins, but can tell childhood events)
mTesting of memory, comprehension, calculations, genci
impaired
DEMENTIA
CLINICAL FEATURES -2
COGNITIVE DISTURBANCES
mAphasia (language disturbance)
mApraxia (inability to carry out motor activity despite intact motor
function
Agnosia (fail
ntact sensory functioning)
, proverbs)
to recognize object «
DEMENTIA
ICAL FEAURES -3
LI
OPERSONALITY CHANGE
Accentuation of pre-morbid traits
"Lose social inhibitions
"Grooming & hygiene impaired
Depressed in the early stages, later labile (pathological laughing or
crying for no reason) or shallow affect
Paranoid symptoms, delusions
DEMENTIA
CLINICAL FEATURES 3:
COMEMORY DISTURBANCE
Okurt Goldstein Catastrophic reaction, reduced abstract thinking
TESTS FOR DEMENTIA
DOMINI MENTAL STATUS
Omemory TESTS
CLINICAL FEATURES =
Oparanoid delusions Fronto-temporal marked personality changes
_ DEMENTIA-
information Cy INICAL FEATURES — 3
Behavioral
CiHallucinations & delusions of a persecutory nature 1SVaFHL WNOLLV ANDO
uosiod ywolpaur ¥ oq you Kew ‘s{sKpoucoyDasd uF paure.sT,
- - ISATVNVOHDASA
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- + SUORLUPNTET —— yyuojdyp so (qr W) 29.48op aUnpwad ysod v PIM aIeNpLAd [worpaut ¥
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SUAAHOSIG STL VIN OASA AO SIAL VLINAWAG
wostox nowy BupyNEy so Supeao peayorempedg,
uosied vorpour u aq Jou Kutt ‘Kdesomoysasd uy paureay, Aepary 5
LSIAVUTHLOHOASA wolssardoqy
Adwsomp penionednooo uy pomrery, poo = WLLNAWAG Psychotherapy :
Acceptance of treatment unwilling Willing
Psychiatrie
Orgar
Brain lesion Bio-psycho-social
LL FEATURES
impaired normal
Intelligence impaired normal
Orientation impaired
Hallucinations visual
PHYSICAL EXAMINATION abnormal Normal
EXAMINATION
MENTAL STATUS
CONATION
MOTOR BEHAVIOR
"IMPULSES,
MOTIVATIONS, DRIVES,
INSTINCTS EXPRESSED BY
A PERONS BEHAVIOR OR
MOTOR ACTIVITY
COGNITION
‘THINKING
MGOAL DIRECTED FLOW
OF IDEASSYMBOLS &
ASSOCIATIONS INITIATED
BY A PROBLEM OR TASK
& LEADING TO A REALITY
ORIENTED SOLUTION
AFFECT
FEELING
OBSERVED EXPRESSION
OF EMOTIONS, POSSIBLY
INCONSISTENT WITH
PATIENT’S DESCRIPTION
OF EMOTION
CONATION
MCONSCIOUSNESS
WALERT
MATTENTION
IGENERAL APPEARANCE
=PSYCHOMOTOR
ACTIVITY
"COMPREHENSION
™CO-OPERATIVE
CONATION -
CONSCIOUSNESS
"CONSCIOUS
CLOUDING
STUPOR
‘SDELIRIUM
COMA
CONATION - ATTENTION
WATTENTIVE/
INATTENTIVE,
BDISTRACTABLE
CONATION - ALERT
MALERT
BWITHDRAWN / GALLVUSdOOOm
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