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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
0
100
200
300
400
500
600
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.