Syndromes of Cognitive Dysfunction

Cognitive function refers to the mental process of knowing things. It includes high-level cortical functions such as memory, language, perception, and executive function (planning, initiating, and reasoning) that generally depend on the alert state and focused attention. Dysfunction of cognition without a change in consciousness may result in various disorders, including aphasia, apraxia, agnosia, executive dysfunction, and memory disorders such as dementia and amnesia. Transient dysfunction of cognition associated with a change in level of consciousness or attention may be due to delirium or confusional states. This chapter broadly introduces the specific definitions of cognitive dysfunction and the overall differential diagnoses.

Anti-MOG autoantibody–associated schizophreniform psychosis

Objective: Autoimmune mechanisms are related to disease development in a subgroup of patients with psychosis. The contribution of immunoglobulin G (IgG) antibodies against myelin oligodendrocyte glycoprotein (MOG) is mainly unclear in this context. Methods: Therefore, two patients with psychosis and anti-MOG antibodies—detected in fixed cell-based and live cell-based assays—are presented. Results: Patient 1 suffered from late-onset psychosis with singular white matter lesions in MRI and intermittent EEG slowing. Patient 2 suffered from a chronic paranoid-hallucinatory disorder with intermittent confusional states, non-specific white matter alterations on MRI, a disorganized alpha rhythm on EEG and elevated cerebrospinal-fluid protein. Both patients had anti-MOG antibody titers of 1:320 in serum (reference<1:20). Conclusion: The arguments for and against a causal role for anti-MOG antibodies are discussed. The antibodies could be relevant, but due to moderate titers, they may have caused a rather “subtle clinical picture” consisting of psychosis instead of “classical” MOG encephalomyelitis.

Suicide and parasuicide pathology in everyday life

Suicide (derived from the words sui = self and cidium = killing) means any case in which death results directly or indirectly from a positive or negative act, committed by the victim him/herself, who knows that it must produce this result (Durkheim). Pseudo-suicidal behaviours (false killings). The notion of suicide tends to be replaced by that of suicidal behaviour, which includes: successful suicide, suicide attempts, suicide ideas, presuicidal syndrome. From the definition of suicide, it follows that it is considered as such that act in relation to which the subject evaluates the consequences. Implicitly, this category will not include deaths that occurred during confusional states, which are accidental (although this article makes examples, exposures, references, differential diagnoses with this pathology as well), crepuscular, epileptic moods, dementia.

Inpatient Diagnosis of Delirium and Encephalopathy: Coding Trends in 2011-2018

Physicians have long debated the diagnosis of acute confusional states as delirium or encephalopathy, often based on specialty. Recently, CMS assigned a lower severity to the nonspecific behavioral diagnosis of delirium than for the pathophysiological diagnosis of encephalopathy, potentially exacerbating these disagreements. Therefore, we sought to evaluate trends in these two diagnoses among hospitalized adults. Using 2011-2018 IBM MarketScan datasets, we identified delirium/encephalopathy patients who were ≥ 18 years and enrolled with medical and pharmacy coverage for each calendar year. Delirium/encephalopathy were defined using validated ICD-9/10 codes among hospitalized patients. We identified the physician specialties associated with the hospitalization and comorbidities using ICD9/10 inpatient/outpatient diagnosis codes within one year prior to the diagnosis of delirium or encephalopathy. Log-binomial models were used to evaluate the trends adjusting for age, gender, insurance and comorbidities. We identified 10,418 delirium and 87,393 encephalopathy hospitalized patients in 2011-2018. Of these patients, the total number of patients with either diagnosis increased, but the proportion of patients with delirium for each year decreased from 20% in 2011 to 9% in 2018. During the 8 years, neurologists and internists increased their use of both diagnoses, whereas psychiatrists only increased for delirium. Patients with encephalopathy are more likely to be older, female, and have more comorbidities. These shifts in diagnosis complicate the study of delirium and encephalopathy, and can lead to erroneous conclusions about trends in the incidence and prevalence of these disorders unless properly understood.

Neurological disorders in Covid-19: clinical involvement and pathophysiological mechanisms

The recent COVID-19 pandemic caused by the SARS-CoV-2 virus has conditioned a severe pulmonary disease with multi-system involvement. Recently, a variety of neurological disorders has been associated with this infection, including lack of smell (anosmia), lack of taste (ageusia), headache, myalgias, confusional states (encephalopathies), dizziness, seizures, strokes, and cranial and peripheral nerve palsies. A direct damage by the virus as well as secondary inflammatory and immune mechanisms triggered by the viral infection may be responsible for the nervous system abnormalities. The virus can gain access to the nervous system from the bloodstream and/or through the peripheral nerves in a retrograde transport. There is no specific therapy for these problems, thus treatment is symptomatic and supportive. Oftentimes a prothrombotic state is created during the infection; hence, anticoagulation should be considered in those patients.

Dilemmasituation: Nächtlicher Unruhezustand beim älteren Patienten

Elderly individuals, particularly those with cognitive impairment, are oftentimes restless during the night, and this increases the distress of relatives, professional carers and themselves. A number of conditions other than dementia need to be considered from nyctophobia and insomnophobia, to pain, specific motor disorders during sleep, parasomnias as REM-sleep behaviour disorder, dipping, hypoglycemia, withdrawal or excessive tea, coffee and alcohol consumption. A clear-cut differential diagnosis between dementia and delirium is not always possible, as dementia is the major risk factor for confusional states decreasing the vulnerability by anticholinergic medication and any other disruptive factor, biological or psychological. Treatment of nocturnal agitation usually requires (1) reassurance and re-orientation; (2a) the discontinuation of anticholinergic substances; (2b) symptomatic psychotropic intervention; and (3) causal treatment of underlying problems. Benzodiazepines should only be used at the lowest necessary dosage for the shortest possible time, particularly in individuals who are already benzodiazepine-dependent. Quetiapine or mirtazapine at low dosages can be employed in patients with psychotic or depressive symptoms. Melatonin and its derivatives hold promise for chronic circadian rhythm disorders. There is no “one fits all” recipe for this notorious problem and each case needs to be examined individually.

Psychische Probleme in der Pandemie – Beobachtungen während der COVID-19-Krise

We have recently observed several clusters of psychiatric symptoms in the context of COVID-19: (1) increased anxiety in psychiatric in- and outpatients with different diagnoses; (2) more cases of domestic violence often associated with increased drug- or alcohol-consumption in offenders and victims; (3) a nihilistic “apocalyptic” syndrome of elderly patients cut-off from their families; (4) visual and acoustic hallucinoses due to pneumonia and sepsis-related confusional states. Cases of chloroquine-related toxicity have been reported elsewhere, but have not been observed in our hospital so far. Mental issues related to COVID-19 reported from China and practical recommendations are briefly summarized. Many patients with serious mental disorders will suffer world-wide due to a reallocation of medical, social and financial ressources.

Iatrogenic delirium on symptom-triggered alcohol withdrawal protocol

Purpose The purpose of this paper is to illustrate delirium as a possible consequence of the application of symptom-triggered therapy for alcohol withdrawal and to explore alternative treatment modalities. In the management of alcohol withdrawal syndrome, symptom-triggered therapy directs nursing staff to regularly assess patients using standardized instruments, such as the Clinical Institute for Withdrawal Assessment of Alcohol, Revised (CIWA-Ar), and administer benzodiazepines at symptom severity thresholds. Symptom-triggered therapy has been shown to lower total benzodiazepine dosage and treatment duration relative to fixed dosage tapers (Daeppen et al., 2002). However, CIWA-Ar has important limitations. Because of its reliance on patient reporting, it is inappropriate for nonverbal patients, non-English speakers (in the absence of readily available translators) and patients in confusional states including delirium and psychosis. Importantly, it also relies on the appropriate selection of patients and considering alternate etiologies for signs and symptoms also associated with alcohol withdrawal. Design/methodology/approach The authors report a case of a 47-year-old male admitted for cardiac arrest because of benzodiazepine and alcohol overdose who developed worsening delirium on CIWA-Ar protocol. Findings While symptom-triggered therapy through instruments such as the CIWA-Ar protocol has shown to lower total benzodiazepine dosage and treatment duration in patients in alcohol withdrawal, over-reliance on such tools may also lead providers to overlook other causes of delirium. Originality/value This case illustrates the necessity for providers to consider using other available assessment and treatment options including objective alcohol withdrawal scales, fixed benzodiazepine dosage tapers and even antiepileptic medications in select patients.