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"Frankly, _________, I just don't give a damn." This is the proper attitude about mindless "facts" that clutter the mind and contribute little to clear thinking and an inventive nature. Being able to relate events, information, data to other events, information and data is the function of the human brain that distinguishes it from that of the animal. But is it necessary to endlessly process information that has no merit?
Such is the case as individuals age. Too much concern is expressed that one over the age of sixty or so, is losing "short-term memory" and has signs of early stages of Alzheimer's disease. In many cases it's just clutter. "Doctor" nurse is often the source of these unwarranted and wrong-headed ideas. But, once launched, a family that has a member in the old-age group is constantly worried about, "what will we do with Dad (or Mom, or Sis, or Bro)." Needless worry. In most cases we are seeing the decline of stimulus. Instead of doing for the aging parent, it is better that they be expected to contribute, do what they can.
Yes, we all know of cases where a highly educated individual of some responsibility has reverted to the nineteen age group. That's Alzheimer's? Of course not, that's merely shirking responsibility and taking advantage of the person's position.
Or how about, when after retirement, the man becomes a couch potato, sitting before the tube, watching movies. That's not early Alzheimers, that's voyeurism. (Maybe the effect is the same?)
Even those that are in their eighties and to someone unfamiliar with the individual would appear to be moody, irritable, fearful or withdrawn, might be diagnosed as a sign of Alzheimers. But to at least some of the family members, that's just the way the individual has always been, sometimes more, sometimes less.
So the best solution is to take life as it is dealt. Challenge those of more mature years with though and action and press for answers. Expect a thoughtful response. This is called, "thinking." Too little time is spent in teaching children how to think and why shouldn't we expect adults to think as well (regardless of age.) Sometimes you hear reference to "thinking out-side the box." No thinking is really outside the box if the individual is taught properly. It only remains for him or her to be able to discriminate between so called "wild" ideas and conventional thought.
Enjoy the dialog with an older person, challenge them and be amazed at the results! You will learn something as well. If in fact the individual develops a mental deficiency, at least the years leading up to that point will have been filled with pleasure for the afflicted and the other one (but which is which(?).)
Whenever, someone suggest that a mature member of society has "early Altzheimer's". Tell them to stuff-it. If they would spend more time acting as a stimulus and less as a bearer of bad news, ever one would be happier.
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The following is extracted from Merck & Co., Inc.'s, "The Merck Manual", an excellent source of information on just about everything that pertains to human health. According to the foreword in the sixteenth edition, "The Manual is the most widely used medical text in the world... its primary purpose remains the same ^ that as many copies are in the hands of individuals with no medical training as those in the hands of physicians.
As one considers conditions of the mind that fall under various categories, it is helpful to take an overview before rushing to judgement. The Manual does an admirable job in focusing attention permitting one to better understand just how different we all are and how what appears to be abnormal in one case is simply individuality and should not be suppressed unless it is harmful to the individual or to those who have the pleasure (?) of his or her company.
Consider this as a review of a section of The Merck Manual. If you like it, buy a copy of the Manual, you will be rewarded for it will be the best money you ever spent!
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DELIRIUM AND CONFUSIONAL STATES
Note: I have added [comments] in some instances where I thought it might help get through the text.
DELIRIUM
A self limited condition characterized by extreme disturbances of arousal, attention, orientation, perception, intellectual function, and effect, often accompanied by fear and agitation. In patients with structural brain damage, an acute delirious reaction may gradually give way to a chronic dementia.
ETIOLOGY
Delirium most often occurs with acute widespread toxic or structural brain disease. It is seen especially during withdrawal from intoxication in chronic abusers of alcohol or barbiturate-like drugs, in acute inflammatory disorders (e.g., encephalitis or meningitis), and occasionally in the elderly with right hemispheric thalamoparietal infarcts [basically a stroke].
SYMPTOMS AND SIGNS
Disorientation, sometimes total (including absence of self-recognition), is characteristic, as are irritability, fear, perceptual delusions, visual hallucinations, and usually intermittently impaired arousal but sometimes sustained insomnia. In most instances, symptoms become worse with nightfall; in some they are confined to the nocturnal hours. Many delirious patients have fever, most are tremulous, and those with drug-alcohol withdrawal are especially likely to convulse. The severe agitation, disorientation, and occasional presence of auditory rather than visual hallucinations sometimes can be confused with severe functional psychosis. Paranoid behavior may become prominent; such patients must be restrained to prevent injury to self or others.
DIFFERENTIAL DIAGNOSIS
The acute or organic reaction must be distinguished from functional disorders before ascertaining the cause. As a rule, defects in orientation, recent memory, simple calculations, and other intellectual tasks identify the organic nature. Fever or evidence of drug use or systemic disease is prominent in delirium and absent in functional psychoses. A psychiatric history of uncontrollable outbursts, manic-depressive illness, or schizophrenic reactions is crucial. Among organic disturbances to be considered are the senseless chatter and occasional agitation of acute Wemicke's fluent aphasia.
TREATMENT
Delirium is dangerous and sometimes fatal, especially in elderly debilitated patients in whom it signifies an advanced stage of systemic disease. The symptom often requires direct therapy beyond that of the underlying disease. Fluids must be restored and electrolytes closely monitored. Infusions should contain prophylactic thiamine and other B-complex vitamins. Fever should be controlled below 39 degrees C (l02.2 degrees F). The severe agitation and tremulousness of delirium tremens are best controlled acutely. using diazepam given slowly IV in 5- to 10-mg doses q 10 to 15 min until the patient is calm but not asleep. Requirements sometimes are considerable, often> 100 mg/day. With less severe agitation. reassurance alone or oral haloperidol (5 to 10 mg lid to q.i.d.) may suffice. Convulsions should be prevented, but if they occur, treated vigorously with diazepam. In chronic barbiturate withdrawal. severe tremulousness that continues for> 72 h should be treated by giving sufficient phenobarbital to stop the tremors. then a slowly decreasing dosage over a manner of days, and ceased only when severe tremulousness stops.
CONFUSIONAL STATES
States less florid than delirium, characteristically having a less abrupt or dramatic on-set, and usually marked by less severe disorientation and more subtle motor signs. Etiology and incidence: Mild confusional states are common, especially among elderly patients exposed to hospital care or the trauma of major surgery. Metabolic encephalopathy due to systemic organ failure, excessive medication, nutritional insufficiency, or systemic infection with fever often adds to underlying traumatic, vascular, or senile cerebral insufficiency. precipitating a confusional state. Symptoms and signs: Apathy and drowsiness often are prominent.
Disorientation is most marked for time, less for place, and almost never for self. Concentration is impaired, and misperceptions and thinking errors occur. Motor abnormalities are common and consist of accentuated physiologic tremor, asterixis, and difficulty in motor relaxation.
Treatment is usually directed at the underlying systemic problem and correction of identifiable metabolic errors as soon as possible. All unnecessary drugs should be withheld; the dosage of even necessary agents should be reevaluated (e.g. digitalis is a well-known cause of confusion or hallucinations in the elderly). Clinical improvement can lag behind correction of metabolic errors, especially in patients> 70 yr.
DEMENTIA
A structurally caused permanent or progressive decline in several dimensions of intellectual function that interferes substantially with the person's normal social or economic activity. More than one million Americans are incapacitated by dementia, which occurs at any age and can follow any injury severe enough to impose widespread damage on the cerebrum's association cortical areas. The increasing prevalence of AIDS can be expected to increase these numbers considerably as an estimated 50% of such patients develop a dementia by the late stages of the disease.
ETIOLOGY AND CLASSIFICATION
Static dementia is fixed in its degree of impairment and usually follows a single major injury (or the last of several -- e.g., severe head trauma, cardiac arrest, or cerebral hemorrhage). Progressive dementia can accompany several major brain disorders; some are discussed below. Others are discussed elsewhere in THE MANUAL e.g., Huntington's disease, chronic drug-alcohol-nutritional abuse, brain tumor, dementia paralytica, Creutxfeldt-Jakob disease, and several degenerative illnesses including Wilson's disease, parkinsonism, multiple sclerosis, and amyotrophic lateral sclerosis.
Alzheimer-type dementia is due to a degenerative process, with a loss of cells from the basal forebrain, cerebral cortex, and other brain areas. Acetylcholine-transmitting neurons and their target nerve cells are particularly affected. The brain shows moderate to marked atrophy with wide sulci and dilated ventricles. Senile plaques and neurofibrillary tangles are present. Memory loss is the most prominent early symptom. Disturbances of arousal do not occur early in the course. Altzheimers's presenile and senile onset dementias are similar in both clinical and pathologic features, with the former commonly beginning in the 5th and 6th decades and the latter in the 7th and 8th decades, sometimes earlier, rarely later. The dementia usually progresses steadily. becoming well advanced in 2 to 3 yr. Pick's disease also presents in the presenile period. has a somewhat slower course, and shows a similar clinical picture. The primary difference is pathologic: Circumscribed convolutional atrophy affects mainly the frontal and temporal lobes. Some cases of dementia that occur in the presenile period are hard to classify and are sometimes labeled idiopathic, or simple presenile dementia. In many instances, these elderly dementias reflect the combined impact on the brain of Alzheimer-like changes, multiple small infarcts. and other less well identified age-associated abnormalities
Multi-infarct dementia is more common in men and begins most often after age 70. Small and large cerebral infarcts of varying ages are present. Hypertensive patients are most susceptible; but hypertension, although frequently associated, is not essential. Because the pathologic process involves infarction, the dementia tends to progress in steps, each one accompanied by intellectual worsening and perhaps the development or aggravation of neurologic signs. In the early stages, personality and insight tend to be better preserved than in senile dementia. Depressive symptoms are common, and suicide is possible. As the condition advances, neurologic features may develop, especially hemiplegias, pseudobulbar palsy, with pathologic laughing and crying, or other signs of extrapyramidal dysfunction. Treatment is similar to that of other forms of cerebral ischemic disease (see Ch. 123). Control of hypertension (if present) is especially important.
AIDS dementia is a frequent manifestation of the later stages of HIV-l infection. Early manifestations include slowed thinking and expression, difficulty in concentration, apathy, all with preserved insight but few manifestations of depression. Motor movements are -slowed; ataxia and weakness may be evident; and abnormal reflexes, including extensor plantar responses, develop. Treatment with zidovudine often induces improvement that is sometimes dramatic.
Chronic communicating hydrocephalus with "normal" pressure can cause an insidiously developing dementia in mid to late middle age, affecting men more than women. Such patients are slow and slovenly, in contrast to the more alert behavior characterizing Alzheimer's disease. The gait is unsteady, slow, and shuffling, and many patients have episodes of urinary incontinence. Pathogenesis is based on impeded CSF circulation and absorption. There may have been a previous attack of meningitis, encephalitis, or head injury, and a few patients have tumors, particularly of the midbrain. CT scans show large dilated ventricles with little or no cortical atrophy. The CSF pressure is normal or high normal. Some improvement may follow the introduction of a ventriculoatrial shunt, especially when gait disorders precede or outweigh mental decline.
A severe head injury may cause sufficient brain damage to result in nonprogressive dementia. With repeated injury, as in boxers, progressive dementia accompanied by extra-pyramidal features (chronic progressive traumatic encephalopathy) may develop even after abandonment of boxing.
SYMPTOMS, SIGNS, AND COURSE
Depression, paranoia, anxiety, or any of several other psychologic symptoms may be the-predominant presenting feature. Early symptoms differ widely from patient to patient. The most common clinical picture is slow disintegration of personality and intellect due to impaired insight and judgment and loss of affect. Usually, disease progression is more painful to the family than to the patient whose interests become restricted, outlook rigid, and conceptual thinking more difficult: some poverty of thought becomes apparent. He may perform familiar tasks well. but has difficulty acquiring new skills. Initiative diminishes, and the patient may become distractible [frenzied or mad]. Eventually with progressive dementia, a global defect develops that involves all aspects of higher cortical function. Along with the cognitive dysfunction, specific disturbances of speech (aphasia), motor activity (apraxia), and recognition of perceptions (agnosia) may be discernible. Spatial disorientation some-times is prominent. Memory impairment increases, beginning with problems recalling recent events or finding names; the impairment varies greatly from time to time and often from moment to moment. Remote memory impairment can be circumvented at first, but also progresses as the defect increases.
In some patients, cognitive dysfunction [CD, becoming unaware of what's going on] is preceded by modifications in their usual behavior and emotional responses. Typically, affect [CD] is blunted [direct, harshness of speech or manner], but in early stages it may be excessive. Normal personality traits may become exaggerated or caricatured; an obsessive patient may be unbearably pedantic and rigid (organic orderliness), or a sociable extrovert may be facile and inappropriately jocular. The initial affective [CD] change may be dominated by irritability, with periods of anger and violence. Depression is common. If the mood change (depression, anxiety, or elation) is sustained, the disorder may be misdiagnosed as a primary affective [CD] condition. Affect [CD] becomes more and more shallow and evanescent [short lived(?)] as the condition progresses, and finally gives way to severe blunting [directness, harshness], masked perhaps by a fatuous [silly or foolish] euphoria [well being or happiness] without depth. Habits deteriorate, and the patient becomes slovenly, dirty. and eventually incontinent, culminating with the need for total nursing care in later stages.
Coexisting neurologic features depend on the distribution and nature of the brain lesions, and these in turn on the etiology. They are marked in some syndromes as described above, in others (e.g., senile dementia) they are unusual despite the widespread atrophic process. While dementia tends to run an insidious, progressive course, it is quite common for patients who have subtle, borderline, or mild signs of dementia to become acutely and severely confused and disturbed. This is usually due to sudden stress (e.g., acute illness of any kind, treatment with brain--affecting drugs, changes in environment, and psychosocial stresses-particularly loss of a close relationship). Typically, the stresses are multiple: an elderly person fractures a hip, is hospitalized, and has anesthesia, surgery drugs for pain, frequent changes of personnel, and moves to a nursing home. Time and judicious care may result in substantial improvement.
DIAGNOSIS
Dagnosis is a matter of clinical judgment. A neuropsychologic diagnosis of dementia should not be accepted if the clinical evaluation is dubious, especially in patients who appear depressed or who may have other primary psychiatric disorders. Psychometric test results can be depended on only when the patient is freely communicative. Muteness or a failure to supply complete answers can result from depression as easily as from dementia.
CT studies also should be correlated with the clinical state. Cerebral cortical "atrophy" increases with age in persons with normal mental status, and CT scan provides no reliable indication of intellectual impairment. The EEG is almost always pathologically slow in organic dementia. Because dementia is sometimes secondary to a treatable condition, adequate investigations must be made unless the cause is obvious. Potentially toxic drugs should be reduced or discontinued. Tests should include a CBC, blood electrolyte screen, serum vitamin B12 level, tests of thyroid function, chest x-rays, CT scan, and STS. Lumbar puncture is seldom independently informative. HIV antibodies should be sought in high-risk patients.
Differentiating dementia from delirium is seldom difficult. The delirious patient usually has a brief history and a more florid illness. An EEG may be helpful in difficult cases, as when a confused patient is seen with no accompanying informant; the EEG disturbance is generally greater in delirium.
Distinguishing dementia from a primary psychiatric disorder may be more difficult. Pseudodementia, a reversible disorder if treated, can closely mimic neuropathologically caused disorders. Though most common in depressed elderly persons, it can occur in patients with schizophrenic or personality disorders as well as in persons chronically intoxicated with sedatives or other drugs. Diagnosis comes from a careful history and mental status examination. Accurate identification of drugs or other toxic factors may require discussion with the family. Depressed patients eat little, are constipated, sleep less than normal, but behave best at night; severely depressed patients tend to complain of memory loss disproportionate to their examination. By contrast, patients with functionally impairing dementia seldom complain of memory problems. Patients with depression give slow answers, but when they do respond, the content often is accurate; they rarely forget major current events or matters of great personal importance; they may be semi-mute, but when they talk, they are not aphasic. Their neurologic examinations are unremarkable and their EEGs usually are normal.
Chronic barbiturate or bromide intoxication. vitamin deficiency states, and myxedema [thyroid insufficiency, sleeps or naps a lot] are potentially treatable conditions that may mimic dementia.
PROGNOSIS
Dementia generally is an insidious, slowly progressive, untreatable condition. However, the rate of progression varies widely and depends on the cause. The disorder may not be progressive, as after a head injury. Removal of alcohol in patients with alcoholic dementia can lead to substantial long-term improvement. In depressed, demented individuals, anti-depressants can substantially (though transiently) improve function.
TREATMENT
The initial management of acute dementia should involve noting whether a prominent recent worsening has occurred in the patient's mental status. This is particularly true when the dementia has suddenly become worse because of stress. Such patients benefit from improvement in a precipitating illness. withdrawal of known toxic drugs. and minimal use of drugs that affect brain metabolism. They require time to adjust to and become familiar with new surroundings, routines, and people.
Quiet. dark private rooms should be avoided. The room should be reasonably bright and provide sensory stimuli such as a bright light and a radio or television set to assist the patient to remain oriented and to focus his attention. However, excessive stimuli should be avoided. Familiar people in attendance and frequent visits by medical personnel encourage the patient to relate. Explanations should be precise and simple, and nonessential procedures omitted. Orientation to time is helped by using large calendars and clocks and routinizing daily activities; orientation to person by medical personnel wearing large name tags and repeatedly introducing themselves.
Patients with dementia should be as much as possible in familiar surroundings with minimal variation in environmental stimuli, yet should he encouraged to continue with performable tasks. Major problems develop when awareness of their difficulties causes them to feel an acute sense of frustration, loss of self esteem, and, at times, overwhelming anxiety (catastrophic reaction).
The family should be counseled and should encourage the patient in activities that promote a sense of participation and accomplishment. As the disease progresses and uncontrollable agitation develops, carefully adjusted doses of haloperidol 0.5 to I mg orally as needed usually provide calming without excessive drowsiness. As persons become socially limited or incapacitated, the use of day care centers, home care aids, disease-related support groups, visiting nurse assistance, or part-time nurses almost invariably becomes necessary. Community hospital social workers or voluntary disease-related health agencies (e.g., the Alzheimer's Disease Association) are useful resources.
TABLE 118-3.
Manifestations Delirium Dementia
Onset Acute or Subacute Insidious
Duration Days to weeks Permanent
Associated conditions Drugs, withdrawal, or systemic No systemic factors illness always present necessary
Nocturnal worsening Almost always Often
Attention Poorly maintained Relatively unaffected
Appearance Slovenly Often neat
Arousal level Fluctuates from lethargy Normal to agitation
Orientation Variable impaired, Impaired if disease almost always for time socially limiting
Thought processes Disorganized; hallucinations and Impoverished; delusions illusions common common
Language Dysarthric, slow, often poorly Nominal amnesia, less often coherent and inappropriate aphasia
Memory Confused Recent memory lost; remote memory impaired
Sleep-wake rhythms Loss of circadian regularity napping Nocturnal sleep commonly often excessive interrupted
[The table format may be screwed up.]
Merck Manual, pp 1402 -1407. 16 ed.
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