altered thinking. rules the symbol ╬ means you should remember this now. other material is for...

Altered Thinking

Rules

• The symbol ╬ means you should remember this now.

• Other material is for context• The lecture will generate three or four multiple

choice questions:One correct answer per questions.

No “all of the following except” questions.

• There is one test question presented today - it will be on the test.

For context: Definitions

Altered: changed.

Change from the patient’s usual state.

Even if the usual state is not on the bell curve.

Thinking:

putting things together,

interpreting things,

assigning the correct (usual) meaning to something.

Objectives

1. Familiarize yourself with some possible causes of altered thinking.

2. List three distinguishing features of delirium.3. Understand clinically relevant misperception of

sensory input (illusion).4. List three distinguishing features of dementia.5. Memorize three causes of dementia.6. Know the diagnostic criteria for depression.

Objective 1: Familiarize yourself with some possible causes of altered thinking. This is for context.

The differential diagnosis of altered thinking includes:

• Delirium• Dementia (Alzheimer’s disease, Pick’s

disease, multi-infarct dementia, vasculitis and microangiopathy, Parkinson’s disease, diffuse Lewy body disease, progressive supranuclear palsy.)

• Depression

Objective 2. List three distinguishing features of delirium.

Definition of Delirium:“Off the track” (implying the patient was on the track). A type of alteration in the way the person is thinking:

interpreting, connecting, assigning the correct meaning to

something.


Delirium is altered thinking accompanied by:Sudden changeIllusion – misperception of sensory stimuliHallucinationReduced cognitionDisturbed sleep wake cycleAgitated (cannot focus)Present in 10% of hospitalized patient; 40% of

geriatric hospitalized patients. *Some of these features are shared by other

causes of altered thinking.

╬ Objective 2. List three distinguishing features of delirium.

╬ 1. Sudden change

╬ 2. Illusion – misperception of sensory stimuli

╬ 3. Hallucination

Reduced cognition, disturbed sleep wake cycle, and agitation are possibly shared with dementia and depression.


Case: 74 year old male hospitalized for left hip replacement.He prepared your neighbor’s taxes - and you know your neighbor “survived” an audit by the IRS. He was fine yesterday.

The night after the surgery: he is screaming from his private room, “call the fire department.” [Sudden change.] He thought the call bell was a fire alarm.

[Illusion – misinterpreting the call bell for a fire alarm]He asks for a raincoat because there is a cloud over his bed, “a rain cloud.”

[Hallucination]There are letters, not numbers, on the sudoku puzzle. [Reduced cognition]It is 3:00 a.m. and he is awake. He is not in pain.

[Altered sleep wake cycle]Then he says, “There goes the fire alarm again! I’ve had enough of this.” He then throws his bedpan (empty) at the nurse.

[Agitation]

Objective 3. Understand clinically relevant misperception of sensory input (illusion).

Would the following misperception of sensory input be relevant to the diagnosis of delirium?

Source: http://clusterfunction.com/images/7_24_off/illusion.jpg

Objective 4. List three distinguishing features of dementia.

Definition of Dementia:

Reduced cognition and

loss of functional autonomy.


Dementia Features - Altered thinking accompanied by:Steady courseNo Illusion; no misperception of sensory stimuliNo HallucinationReduced cognitionAgitation (possible)Disturbed sleep wake cycle (possible).Present in 10% of people over 65; 50% of people over 85. Not all of these features are present all of the time in

people with dementia.


╬ 1. Stable course. (A steady and slow – rather than sudden – decline).

╬ 2. No illusion.

╬ 3. No hallucination. Reduced cognition, disturbed sleep wake cycle, and agitation are possibly shared with delirium and depression.


Case:• 65 year old female who has a Ph.D. in mathematics. • Two years ago she started to develop memory problems. She had

to retire because over time it became, “too much.” [Steady course]• No illusion or hallucinations are noted. [No Illusion or

hallucination]• She was once a competitive sudoku champion. She has placed

letters into the sudoku boxes. [Reduced cognition]• She was reported to be looking for the slide rule at 3:00 a.m. the

other night. [Altered sleep wake cycle]• She found her old slide rule but became frustrated because she

couldn’t use it. She threw it through the window - breaking the window. [Agitation]

• She seemed to be more agitated as time went by and spent a lot of time walking around looking for things; however, that has slowed down over the past six months.


Mini mental status examination.

A useful tool to:

help diagnose cognitive decline

follow patients with a progressive decline.

One point for each correct

Name 3 unrelated objects First repetition = score If score < 3 repeat until 3 recalled

Begin at 100 and count backwards by 7s. Stop after five, i.e. 93, 86, 79, 72, 65. If patient cannot do the math, have world spelled backwards: Score = number in correct order, e.g. d l r o w = 5; d l r w o = 3 Self explanatory 1 point for pencil; 1 point for watch Self explanatory 1 point for each part done correctly Write, “Close your eyes.” If they do = 1 Don’t dictate the sentence. Must have a verb, noun, and made sense. Punctuation doesn’t count.

Draw intersecting pentagons.

Each side about one inch and ask him or her to copy it exactly as it is.

All ten angles must be present and two must intersect to score 1 point. Tremor and rotation are ignored.

≥ 25 = Normal

21 to 24 May be dementia

≤ 20 = Dementia

Source: http://www.alzheimers.org.uk/Working_with_people_with_dementia/Primary_care/Dementia_diagnosis_and_management_in_primary_care/mmse.html

Objective 5. Memorize three causes of dementia.

For context: some causes of dementia.• Alzheimer’s disease. • Multi-infarct dementia. • Parkinson’s disease. • Vasculitis and microangiopathy. • Pick’s disease.• Diffuse Lewy body disease.• Progressive supranuclear palsy.

Purpose of this slide is to have you see a differential diagnosis for dementia as not all of these diseases are primarily discussed in the context of dementia, i.e. this is to give you perspective.


╬ 1. Alzheimer’s disease.

╬ 2. Multi-infarct dementia.

╬ 3. Parkinson’s disease.


1. Alzheimer’s disease:

Most common cause of dementia.

Rarely seen before age 45.

Familial cases are occasionally seen.


1. Alzheimer’s disease:

Classically progressive dementia over years.

CT: nonspecific cerebral atrophy with enlarged ventricles

Treatment: there are treatments that help.

Mean survival: 8 years. A common cause of death is pneumonia.

Objective 5. Memorize three causes of dementia.2. Multi infarct dementia:

Second most common cause of dementia. Accounts for 10% of cases. Caused by an accumulation of the defects through bilateral localized infarcts.Mainly after age 50. Males > FemalesCourse is often step wise with each infarct rather than progressive. Diagnosis: history and multiple infarcts on CT or MRI. Treatment: Primary prevention (control hypertension, diabetes mellitus, cardiac disease associated with emboli formation, hyperlipidemia, tobacco use.. Secondary prevention of atherosclerosis, hypertension control, and give aspirin.)

3. Parkinson’s disease – For now remember it is associated with dementia. (Other details in other lectures.


For context: some causes of dementia.• Alzheimer’s disease.• Multi-infarct dementia.• Parkinson’s disease.

• Vasculitis and microangiopathy. Uncommon but amenable to treatment. These include: poyarteritis nodosa, Systemic Lupus Erythematosis, Giant-cell arteritis, Thromobic angiopathies.

• Pick’s disease.• Diffuse Lewy body disease.• Progressive supranuclear palsy.


For context: some causes of dementia.• Alzheimer’s disease.• Multi-infarct dementia.• Parkinson’s disease.• Vasculitis and microangiopathy.

• Pick’s disease.

Rare.

Accompanied by severe cerebral atrophy.

Argyrophilic bodies, called Pick bodies, are in the neuronal cytoplasm.

Cause is unknown – although autosomal dominant in some families.

No treatment. Death in 2 to 5 years.6. Diffuse Lewy body disease.

7. Progressive supranuclear palsy.


For context: some causes of dementia.• Alzheimer’s disease.• Multi-infarct dementia.• Parkinson’s disease.• Vasculitis and microangiopathy.• Pick’s disease.

• Diffuse Lewy body disease. (you will learn about this later).

• Progressive supranuclear palsy. (you will learn about this later).

Objective 6. Know the diagnostic criteria for depression.

Diagnostic criteria:(5 of the following for 2 wks) 1. depressed mood*2. reduced interest*3. weight change 4. change in sleep 5. change in psychomotor (agitated or retardation)6. fatigue7. thoughts of death or suicide *(must include either depressed mood or loss of

interest or pleasure)

╬


Course: varies

Sleep: insomnia or hypersomnia

Illusion: normal perception

Hallucination: may be present if severe.

Present in 5% to 20% of the elderly.

GUARANTEED TEST QUESTION A 94 year old lawyer hospitalized for a left total knee replacement. He has a case scheduled for two weeks from now. His physician visits him on rounds.

The patient states “my room mate is doing magic. He’s really good. He made a one dollar bill turn into a twenty dollar bill.” The patient has a correctly completed the New York Times Sunday Crossword puzzle. He wrote, “26 minutes,” on the puzzle.

The 94 year old man’s room mate has three decks of cards on his table, and a copy of a magazine, “Genii – The Conjurer’s Magazine.” Vol. 62, No. 8 (Aug. 1999).” He is reading about the, “First Lady of Magic”: Melinda Saxe.

The 94 year old patient was recently widowed. He states, “I’ve lost a few pounds and sometimes can’t sleep since she died; however, I’m not really depressed: I had a very loving relationship with my wife. She was in a lot of pain and it was time to go. Judging by actuarial tables I am likely to join her soon anyway . . . but, there is no need to hurry the timing of the reunion, she was always very patient. Remember, Dr. Doogie, not everyone my age is demented!” Which of the following is most true?

a. The 94 year old is in a state of delirium and depressed.

[HE DOES NOT HAVE A DEPRESSED MOOD AND IS NOT HAVING CLINICALLY RELEVANT ILLUSION.]

b. The 94 year old is delirious but not depressed.

[HE IS NOT HAVING CLINICALLY RELEVANT ILLUSION.]

c. The 94 year old is depressed but not delirious.

[HIS MOOD IS NOT DEPRESSED].

d. The 94 year old is neither depressed nor delirious. (correct answer)

e. The 94 year old has Alzheimer’s disease.

[HE DOES NOT HAVE COGNITIVE IMPAREMENT.]

Study guide

Study guide

The following seven slides are to help with efficient study for the test.

Set the power point to “Appear.” Let the previous part of the slide act as a

prompt (serve as a flash card) for what you should know that follows.

Delirium Dementia Depression

Course: Sudden change ≠ ≠ Stable course ≠ = ≠ = ≠ Course varies

Illusion?: Illusion ≠ ≠ ≠ ≠ ≠ ≠No illusion ≠ ≠ ≠ ≠ ≠ ≠ ≠ No illusion

Hallucination?: Hallucination ≠ ≠ ≠ No hallucination ≠ ≠ ≠ ≠ ≠May Hallucinate

Cognition: Reduced cognition = Reduced cognition ≠ ≠ ≠ Cognition intact

Sleep: Disturbed sleep wake = Disturbed sleep wake = = = = Disturbed sleep

wake Agitation:

Agitation = = = = = Agitation ≠ = ≠ = ≠ = ≠ ± Agitation

CompareStudy slide 1 of 7

Objective 2. List three distinguishing features of delirium:

1. Sudden change

2. Illusion

3. Hallucination

Objective 4. List three distinguishing features of dementia:

1. Stable course

2. No illusion.

3. No hallucination.

Objective 5. Memorize three causes of dementia:

1. Alzheimer’s disease.

2. Multi-infarct dementia.

3. Parkinson’s disease.

Objective 6. Know the diagnostic criteria for depression: (5 for 2 wks)

1. Depressed mood *(must include depressed mood or loss of interest or pleasure)

2. Reduced interest

3. Weight change

4. change in sleep

5. Change in psychomotor (agitated or retardation)

6. Fatigue

7. Thoughts of death or suicide.

∑

Study slide 2 of 7

╬ Objective 2. List three distinguishing features of delirium.

╬ 1. Sudden change

╬ 2. Illusion – misperception of sensory stimuli

╬ 3. Hallucination

Reduced cognition, disturbed sleep wake cycle, and agitation are possibly shared with dementia and depression.

Study slide 3 of 7


╬ 1. Stable course. (A steady and slow – rather than sudden – decline).

╬ 2. No illusion.

╬ 3. No hallucination. Reduced cognition, disturbed sleep wake cycle, and agitation are possibly shared with delirium and depression.

Study slide 4 of 7


╬ 1. Alzheimer’s disease.

╬ 2. Multi-infarct dementia.

╬ 3. Parkinson’s disease.

Study slide 5 of 7


Diagnostic criteria:(5 of the following for 2 wks) 1. depressed mood*2. reduced interest*3. weight change 4. change in sleep 5. change in psychomotor (agitated or retardation)6. fatigue7. thoughts of death or suicide *(must include either depressed mood or loss of

interest or pleasure)

╬

Study slide 6 of 7

GUARANTEED TEST QUESTION A 94 year old lawyer hospitalized for a left total knee replacement. He has a case scheduled for two weeks from now. His physician visits him on rounds.

The patient states “my room mate is doing magic. He’s really good. He made a one dollar bill turn into a twenty dollar bill.” The patient has a correctly completed the New York Times Sunday Crossword puzzle. He wrote, “26 minutes,” on the puzzle.

The 94 year old man’s room mate has three decks of cards on his table, and a copy of a magazine, “Genii – The Conjurer’s Magazine.” Vol. 62, No. 8 (Aug. 1999).” He is reading about the, “First Lady of Magic”: Melinda Saxe.

The 94 year old patient was recently widowed. He states, “I’ve lost a few pounds and sometimes can’t sleep since she died; however, I’m not really depressed: I had a very loving relationship with my wife. She was in a lot of pain and it was time to go. Judging by actuarial tables I am likely to join her soon anyway . . . but, there is no need to hurry the timing of the reunion, she was always very patient. Remember, Dr. Doogie, not everyone my age is demented!” Which of the following is most true?

a. The 94 year old is in a state of delirium and depressed.

[HE DOES NOT HAVE A DEPRESSED MOOD AND IS NOT HAVING CLINICALLY RELEVANT ILLUSION.]

b. The 94 year old is delirious but not depressed.

[HE IS NOT HAVING CLINICALLY RELEVANT ILLUSION.]

c. The 94 year old is depressed but not delirious.

[HIS MOOD IS NOT DEPRESSED].

d. The 94 year old is neither depressed nor delirious. (correct answer)

e. The 94 year old has Alzheimer’s disease.

[HE DOES NOT HAVE COGNITIVE IMPAREMENT.]

We end with an illusion. Watch the center of the screen until you are told to look away.

http://www.youtube.com/watch?v=Nnd4cNZJ5oI





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