COGNITIVE

DISORDERS
Sonny T. Lisal

DSM IV (TR)

Cognition includes memory, language,

orientation, judgment, conducting
interpersonal relationships, performing
actions (praxis), and problem solving
Cognitive disorders reflect disruption
in one or more of the above domains,
and are also frequently complicated by
behavioral symptoms

In the past: these conditions were classified

under the heading organic mental disorder or
organic brain disorders.
Traditionally, those disorders had an identifiable
pathological condition such as brain tumor,
cerebrovascular disease, or drug intoxication.
Those brain disorders with no generally
accepted organic basis (e.g., depression) were
called functional disorders
This century-old distinction between organic
and functional disorders is outdated and has
been deleted from the nomenclature. Every
psychiatric disorder has an organic (i.e.,
biological or chemical) component.

ICD-10

In the ICD-10, rather than being

deleted, the term organic implies only
that the syndrome can be attributed to
an independently diagnosable cerebral
or systemic disease or disorder
Primary dysfunction affects the brain
directly; secondary dysfunctions occur
as a result of diseases or disorders
attacking several organs or body
systems, including the brain

Categories included as organic mental

disorders, including symptomatic ones, in ICD10 are:

Dementia

Delirum

Dementia in Alzheimer's disease

Vascular dementia
Dementia in other diseases classified elsewhere (e.g.,
dementia in Pick's disease)
Unspecified dementia; organic amnesia syndrome, not
induced by alcohol and other psychoactive substances
Not induced by alcohol and other psychoactive substances

Other mental disorders from brain damage and

dysfunction and caused by physical disease (e.g.,
organic mood disorders caused by brain disease,
damage, and dysfunction)
Unspecified organic or symptomatic mental disorder

DELIRIUM

Acute onset of fluctuating cognitive impairment and a

disturbance of consciousness
Delirium is a syndrome, not a disease, and it has
many causes, all of which result in a similar pattern
of signs and symptoms relating to the patient's level
of consciousness and cognitive impairment
The hallmark symptom of delirium is an impairment
of consciousness, usually occurring in association
with global impairments of cognitive functions.
Abnormalities of mood, perception, and behavior are
common psychiatric symptoms; tremor, asterixis,
nystagmus, incoordination, and urinary incontinence
are common neurological symptoms
Classically, delirium has a sudden onset (hours or
days), a brief and fluctuating course, and rapid
improvement when the causative factor is identified
and eliminated, but each of these characteristic
features can vary in individual patients

Epidemiology

Prevalence (general population): 0.4% (1854 years) & 1.1 %(> 55)1
10 to 30 % of medically ill patients
(hospital) delirium
30 % surgical intensive care units &
cardiac intensive care units
40-50 % recovering from surgery for hip
fractures have an episode of delirium
> 90% postcardiotomy patients
20 % severe burns
30-40% AIDS have episodes of delirium
while they are hospitalized

Etiology

Central nervous system disease: Seizure, Migraine, Head

trauma, Brain tumor, Hemorrhage/ ischemia
Metabolic disorder (Electrolyte abnormalities, Diabetes,
hypoglycemia, hyperglycemia, or insulin resistance )
Systemic diseases

Infection
Trauma
Change in fluid status (dehydration or volume overload)
Nutritional deficiency
Burns
Uncontrolled pain
Heat stroke
High altitude (usually >5,000 m)

Intoxication or withdrawal from pharmacological or toxic

agents

Intoxication and withdrawal

Heavy metals and aluminum
Pain medications

Diagnostic Criteria (ICD-10)

There is clouding of consciousness, i.e., reduced clarity of awareness
of the environment, with reduced ability to focus, sustain, or shift
attention.
Disturbance of cognition is manifest by both:

A.

B.

At least one of the following psychomotor disturbances is present:

C.

F.

rapid, unpredictable shifts from hypoactivity to hyperactivity;

increased reaction time;
increased or decreased flow of speech;
enhanced startle reaction.

There is disturbance of sleep or of the sleep-wake cycle, manifest by at

least one of the following:

D.

E.

impairment of immediate recall and recent memory, with relatively intact

remote memory;
disorientation in time, place, or person.

insomnia, which in severe cases may involve total sleep loss, with or without
daytime drowsiness, or reversal of the sleep-wake cycle;
nocturnal worsening of symptoms;
disturbing dreams and nightmares, which may continue as hallucinations or
illusions after awakening.

Symptoms have rapid onset and show fluctuations over the course of
the day.
There is objective evidence from history, physical and neurological
examination, or laboratory tests of an underlying cerebral or systemic
disease (other than psychoactive substance-related) that can be
presumed to be responsible for the clinical manifestations in Criteria
D.

Differential Diagnosis

Dementia
Schizophrenia
Depression

Dementia

A progressive impairment of cognitive functions occurring

in clear consciousness (i.e., in the absence of delirium).
Dementia consists of a variety of symptoms that suggest
chronic and widespread dysfunction. Global impairment of
intellect is the essential feature, manifested as difficulty
with memory, attention, thinking, and comprehension.
Other mental functions can often be affected, including
mood, personality, judgment, and social behavior.
The disorder can be progressive or static, permanent or
reversible.
An underlying cause is always assumed, although, in rare
cases, it is impossible to determine a specific cause
The potential reversibility of dementia is related to the
underlying pathological condition and to the availability
and application of effective treatment
Approximately 15 percent of people with dementia have
reversible illnesses if treatment is initiated before
irreversible damage takes place.

Epidemiology

The prevalence of moderate to severe

dementia: 5 % (> 65 years), 20-40 % (>
85 years)
15-20 % in outpatient general medical
practices
50 % in chronic care facilities.

Etiology

Degenerative dementia: Alzheimer's disease, Frontotemporal dementias

(e.g., Pick's disease), Parkinson's disease, Lewy body dementia, Idiopathic
cerebral ferrocalcinosis (Fahr's disease), Progressive supranuclear palsy
Miscellaneous: Huntington's disease, Wilson's disease, Metachromatic
leukodystrophy, Neuroacanthocytosis
Psychiatric: Pseudodementia of depression, Cognitive decline in late-life
schizophrenia
Physiologic: Normal pressure hydrocephalus
Metabolic: Vitamin deficiencies (e.g., vitamin B12, folate) ,
Endocrinopathies (e.g., hypothyroidism), Chronic metabolic disturbances
(e.g., uremia)
Tumor:Primary or metastatic (e.g., meningioma or metastatic breast or
lung cancer)
Traumatic: Dementia pugilistica, posttraumatic dementia, Subdural
hematoma
Infection: Prion diseases (e.g., Creutzfeldt-Jakob disease, bovine
spongiform encephalitis, Gerstmann-Strussler syndrome) , Acquired
immune deficiency syndrome (AIDS), Syphilis
Cardiac, vascular, and anoxia: Infarction (single or multiple or strategic
lacunar), Binswanger's disease (subcortical arteriosclerotic
encephalopathy), Hemodynamic insufficiency (e.g., hypoperfusion or
hypoxia)
Demyelinating diseases: Multiple sclerosis
Drugs and toxins: Alcohol, Heavy metals, Irradiation, Pseudodementia
due to medications (e.g., anticholinergics), Carbon monoxide

Diagnostic Criteria
1.

There is evidence of each of the following

1.

2.

2.

3.

4.

A decline in memory, which is most evident in the learning of

new information, although, in more severe cases, the recall of
previously learned information may also be affected
A decline in other cognitive abilities characterized by
deterioration in judgment and thinking, such as planning and
organizing, and in the general processing of information

Awareness of the environment (i.e., absence of clouding of

consciousness [as defined in delirium, not induced by
alcohol and other psychoactive substances ) is preserved
during a period sufficiently long to allow the unequivocal
demonstration of the symptoms . When there are
superimposed episodes of delirium, the diagnosis of
dementia should be deferred.
There is a decline in emotional control or motivation, or a
change in social behavior manifest as at least one of the
following: emotional lability, irritability, apathy, coarsening
of social behavior
The symptoms should have been present for at least 6
months; if the period since the manifest onset is shorter,
the diagnosis can be only tentative.

Diagnostic Criteria for Dementia in

Alzheimer's Disease

1.
2.

The general criteria for dementia must be met.

There is no evidence from the history, physical
examination, or special investigations for any other
possible cause of dementia (e.g., cerebrovascular
disease, HIV disease, Parkinson's disease, Huntington's
disease, normal pressure hydrocephalus), a systemic
disorder (e.g., hypothyroidism, vitamin B12 or folic
acid deficiency, hypercalcemia), or alcohol or drug
abuse

Type:

Dementia in Alzheimer's disease with early onset

The age at onset must be below 65 years.

In addition, at least one of the following requirements must be
met:

evidence of a relatively rapid onset and progression;

in addition to memory impairment, there must be aphasia (amnesic
or sensory), agraphia, alexia, acalculia, or apraxia (indicating the
presence of temporal, parietal, and/or frontal lobe involvement).

Dementia in Alzheimer's disease with late onset

The age at onset must be 65 years or more.

In addition, at least one of the following requirements must be
met:

evidence of a very slow, gradual onset and progression (the rate of

the latter may be known only retrospectively after a course of 3
years or more);
predominance of memory impairment over intellectual impairment

Diagnostic Criteria for Vascular

Dementia
1.
2.

3.

The general criteria for dementia must be met

Deficits in higher cognitive functions are unevenly
distributed, with some functions affected and others
relatively spared. Thus, memory may be markedly
affected while thinking, reasoning, and information
processing may show only mild decline
There is clinical evidence of focal brain damage,
manifest as at least one of the following:

4.

lateral spastic weakness of the limbs

unilaterally increased tendon reflexes
extensor plantar response
pseudobulbar palsy

There is evidence from the history, examination, or

tests of a significant cerebrovascular disease, which
may reasonably be judged to be etiologically related
to the dementia (e.g., a history of stroke, evidence of
cerebral infarction).

Type:

Vascular dementia of acute onset

The general criteria for vascular dementia

must be met.
The dementia develops rapidly (i.e., usually
within 1 month, but within no longer than 3
months) after succession of strokes or (rarely)
after a single large infarction.

Multi-infarct dementia

The general criteria for vascular dementia

must be met.
The onset of the dementia is gradual (i.e.,
within 6 months), following a number of
minor ischemic episodes.

Subcortical vascular dementia

Mixed cortical and subcortical vascular

dementia

The general criteria for vascular dementia must be

met.
There is a history of hypertension.
There is evidence from clinical examination and
special investigation of vascular disease located in the
deep white matter of the cerebral hemispheres, with
preservation of the cerebral cortex.

Mixed cortical and subcortical components of the

vascular dementia may be suspected from the clinical
features, the results of investigation (including
autopsy), or both

Other vascular dementia

Vascular dementia, unspecified
Dementia in Pick's disease
Dementia in Creutzfeldt-Jakob disease

Differential Diagnosis

Dementia of the Alzheimer's Type

versus Vascular Dementia
Vascular Dementia versus Transient
Ischemic Attacks
Delirium
Depression
Factitious Disorder
Schizophrenia
Normal Aging

Amnestic Disorders

The amnestic disorders are a broad category that

includes a variety of diseases and conditions that
present with an amnestic syndrome.
The syndrome is defined primarily by impairment
in the ability to create new memories.
Three variations of the amnestic disorder
diagnosis, (differing in etiology):

Amnestic disorder caused by a general medical

condition (e.g., head trauma)
Substance-induced persisting amnestic disorder (e.g.,
caused by carbon monoxide poisoning or chronic alcohol
consumption)
Amnestic disorder not otherwise specified for cases in
which the etiology is unclear

Two modifiers:
1.
2.

Transient, for duration less than 1 month

Chronic, for conditions extending beyond 1 month

Epidemiology
No adequate data
Amnesia is most commonly found in
alcohol use disorders and in head
injury
Frequency of amnesia related to
chronic alcohol abuse has
decreased, and the frequency of
amnesia related to head trauma has
increased

Etiology

Systemic medical conditions

Thiamine deficiency (Korsakoff's syndrome)
Hypoglycemia
Primary brain conditions

Seizures
Head trauma (closed and penetrating)
Cerebral tumors (especially thalamic and temporal lobe)
Cerebrovascular diseases (especially thalamic and temporal lobe)
Surgical procedures on the brain
Encephalitis due to herpes simplex
Hypoxia (including nonfatal hanging attempts and carbon monoxide
poisoning)
Transient global amnesia
Electroconvulsive therapy
Multiple sclerosis

Substance-related causes

Alcohol use disorders

Neurotoxins
Benzodiazepines (and other sedative-hypnotics)
Many over-the-counter preparations

Diagnostic Criteria for Organic Amnesic

Syndrome, Not Induced by Alcohol and Other
Psychoactive Substances
There is memory impairment, manifest in both

1.

There is no

2.

3.

A defect of recent memory (impaired learning of new material)

to a degree sufficient to interfere with daily living
A reduced ability to recall past experiences
Defect in immediate recall (as tested, for example, by the digit
span)
Clouding of consciousness and disturbance of attention.
Delirium, not induced by alcohol and other psychoactive
substances
Global intellectual decline (dementia)

There is objective evidence (from physical and

neurological examination, laboratory tests) and/or
history of an insult to, or a disease of, the brain
(especially involving bilaterally the diencephalic and
medial temporal structures but other than alcohol
encephalopathy) that can reasonably be presumed to
be responsible for the clinical manifestations

Differential Diagnosis

Dementia and Delirium

Normal Aging
Dissociative Disorders
Factitious Disorders