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consequences of one s actions are often present The course depends on the underlying cause (eg, frontal lobe contusion may resolve completely)
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Dementia is usually progressive, more common in the elderly, and rarely reversible even if underlying disease can be corrected Dementia can be classified as cortical or subcortical There are three types of cortical dementia: (1) primary degenerative dementia (eg, Alzheimer s), accounting for about 50 60% of cases; (2) atherosclerotic (multi-infarct) dementia, 15 20% of cases (this figure is probably low because of the tendency to overuse the diagnosis of Alzheimer s dementia); and (3) mixtures of the first two types or dementia due to miscellaneous causes, 15 20% of cases (see also 4) Examples of primary degenerative dementia are Alzheimer s dementia (most common) and Pick, Creutzfeldt-Jakob, and Huntington dementias (less common) In all types, loss of impulse control (sexual and language) is common The tenuous level of functioning makes the individual most susceptible to minor physical and psychological stresses The course depends on the underlying cause, and the general trend is steady deterioration HIV infection can produce a primary neurogenic disorder (partially due to neuronal loss) and secondary effects due to opportunistic infections, neoplasias, or the effects of drug therapy At present there has been a reduction in dementia symptoms in both early and late stages, perhaps due to earlier use of zidovudine The general trend is variable, and patients require ongoing monitoring of neuropsychiatric status Pseudodementia is a term applied to depressed patients who appear to be demented These patients are often identifiable by their tendency to complain about memory problems vociferously rather than try to cover them up They usually say they can t complete cognitive tasks but with encouragement can often do so They can be considered to have depressioninduced reversible dementia that remits when the depression resolves
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The differential diagnosis consists mainly of schizophrenia and the other psychoses, which are sometimes confused with cognitive disorders and are often accompanied by psychotic symptoms
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Chronicity may result from delayed correction of the defect, eg, subdural hematoma, low-pressure hydrocephalus Accidents secondary to impulsive behavior and poor judgment are a major consideration Secondary depression and impulsive behavior not infrequently lead to suicide attempts Drugs particularly sedatives may worsen thinking abilities and contribute to the overall problems
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(See also 4)
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Delirium should be considered a syndrome of acute brain dysfunction analogous to acute renal failure The first aim of treatment is to identify and correct the etiologic medical problem Evaluation should consist of a comprehensive physical examination including a search for neurologic abnormalities, infection, or hypoxia Routine laboratory tests may include serum electrolytes, serum glucose, BUN, serum creatinine, liver function tests, thyroid function tests, arterial blood gases, complete blood count, serum calcium, phosphorus, magnesium, vitamin B12, folate, blood cultures, urinalysis, and cerebrospinal fluid analysis Discontinue drugs that may be contributing to the problem (eg, analgesics, corticosteroids, cimetidine, lidocaine, anticholinergic drugs, central nervous system depressants, mefloquine) Do not overlook any possibility of reversible organic disease Electroencephalography, CT, and MRI evaluations may be helpful in diagnosis Ideally, the patient should be monitored without further medications while the evaluation is carried out There are, however, two indications for medication in delirious states: behavioral control (eg, pulling out lines) and subjective distress (eg, pronounced fear due to hallucinations) If these indications are present, medications may be used If there is any hint of alcohol or substance withdrawal (the most common cause of delirium in the general hospital), a benzodiazepine such as lorazepam (1 2 mg every hour) can be given parenterally If there is little likelihood of withdrawal syndrome, haloperidol is often used in doses of 1 10 mg every hour Given intravenously, it appears to impose slight risk of extrapyramidal side effects In addition to the medication, a pleasant, comfortable, nonthreatening, and physically safe environment with adequate nursing or attendant services should be provided Once the underlying condition has been identified and treated, adjunctive medications can be tapered Treatment of dementia syndrome usually involves symptomatic management with one exception Since there is a
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