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Dementia

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Phenomenology

Dementia

PDisorder of Cognitive Function

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The Cognitive Functions

Attention and ConcentrationLanguage functionMemoryVisuospatial AbilityPerceptual CapacityConceptualization and Abstract ReasoningGeneral Intelligence

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Dementia

Other aspects of The MSE

PGeneral Presentationvaried with levelcare taking

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Dementia

Other aspects of The MSE

PEmotionsMood

BGenerally euthymicBdysphoria, frustration early on

BMay become Aagitated@ or Airritable@Affect

BMay be appropriateBBluntedBInappropriate

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Dementia

Other aspects of The MSE

PThoughtProcess

BimpoverishedContent

Bhallucinations rareB> w/ Sensory impairment

Bdelusions Bpoorly formed

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Neuritic Plaques

PAmyloid accumulation

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Tangles and Degeneration

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Delirium vs. Dementia

Things Different

PDeliriumBusually reversibleDementia rarely soPPathologyDementia: BUsually identifiable pathological findingsBat least on autopsyDeliriumBmore often physiological

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Drugs approved for AD

• Cholinesterase Inhibitors– Tachrine (Cognex)– donepezil (Aricept)– rivastigmine (Exelon)– galantamine (Reminyl)

• NMDA antagonists– Memantine (Axura)

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Treatment of Dementia

Non-pharm. treatments

Psychosocial TreatmentsBProvide structureBAdjust to ability

Attention to the care giversEducation

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Child Psychiatry

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“A Child is a Psychotic Dwarf with a Good Prognosis”

Anonymous Adult Psychiatrist

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Kids get it too…

• drug abuse

• Depression

• Mania

• Anxiety

• Schizophrenia

• But full syndrome may not yet be present

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Same thing, different name:

• Conduct disorder = antisocial PD

• Identity dis.= borderline PD

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Early and only in C/A

• Reactive attachment

• Eating/elimination

• Separation anxiety

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Never in C/A

• Organic mental diseases of aging

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Early and Forever

• MR

• Autism

• LD

• ADHD

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ADHD

• Inattention

• Hyperactivity and Impulsivity

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Inattention

– Cannot focus or sustain tasks– Careless mistakes– Poor organization– Forgetful, easily distracted

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Hyperactivity

• Hyperactivity– Fidgety, gets up a lot.– Runs, climbs, moves around inappropriately– Talks a lot, Cannot quiet down.

• Impulsivity– Blurts things out, can’t wait turn– Interrupts.

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Epidemiology

• 3-10%

• Changing definitions

• ♂:♀ = 3:1

• Increase of adult ADHD.

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Etiology

• Runsin families.

• Association with other disorders– Mood, antisocial, substance abuse, learning.

• Possible link with mutation on D4 gene

– May make clinical sense

• Prenatal factors

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Imaging studies

• Decreased volume and hypoperfusion of prefrontal and basal ganglia

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Course of ADHD

• Variable

• Abt ½ do well

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Treatment

• Pharmacological treatment– Psychostimulants

• Amphetamines

• others

– Antidepressants • TCAs

• bupropion

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Psychotherapies

• Behavioral therapy.– Positive reinforcement– Firm, nonpunitive limit setting.

• Environmental management– Decrease distraction in the environment

• Education– Of parents.

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Some general points about psychotherapy in children.

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1991 1992 1993 1994 1995 1996 1997 1998

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100

200

300

400

500

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Tricyclic SSRI

Newer atypicals

Use of Antidepressants

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Dramatic Increase in Psychopharm

• everything is biological• newer drugs are much safer• you don't need the full diagnosis anymore (symptomatic

medicine)– treating the partial syndrome (schizophrenia, mania, anxiety,

disorders, personality disorders).• hello polypharmacy

– adjunctives – nonspecific use (antipsychotics for agitation, mood stabilizers for

aggressivity, SSRI for "neurosis")• "ask your doctor about Prozac“• managed care

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Medications in Children

• psychostimulants (dx., abuse)• antidepressants (old and new)• antipsychotics (old and new)• anti-anxiety (addictive, the street)• mood stabilizers (all the rage, taper the antiseizure meds, slowly)• antiaggressivity (clonidine, tenex)• (autonomic, N.S. effect)• increase and decrease slowly• tapering side effects • can include serotonin-like syndrome, increased BP, withdrawal,

agitation, seizures, recurrence of psychotic symptoms• the tendency toward non-compliance.