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PS19 Psychiatry Toronto Notes 2023

Treatment

• psychological:psychoeducation, CBT (focusing on both in vivo and virtual exposure therapy,

gradually facing feared situations)

• biological:minimal role for medications

Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder

DSM-5 DIAGNOSTIC CRITERIA FOR OBSESSIVE-COMPULSIVE DISORDER

Reprintedwithpermissionhorn the Diagnostic andStatistical Manual of Mental Disorders.5thed.2013.AmericanPsychiatricAssociation

A.presence of obsessions, compulsions, or both

* obsessions are defined by (1) and (2)

1. recurrent and persistent thoughts, urges,orimagesthat are experienced, at some time

during the disturbance, asintrusive and unwanted,and that in most individuals cause

marked anxiety or distress

2. the individual attemptsto ignore orsuppresssuch thoughts, urges, or images,or to

neutralize them with some other thought or action (Le.by performing a compulsion)

compulsions are defined by (1) and (2)

1. repetitive behaviours (e.g.hand washing, ordering, checking) or mental acts(e.g. praying,

counting, repeating wordssilently) that the individual feels driven to perform in response to

an obsession or according to rulesthat must be applied rigidly

2. the behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or

presenting some dreaded event or situation; however, these behaviours or mental acts are

not connected in a realistic way with what they are designed to neutralize or prevent, or are

clearly excessive

B.the obsessions or compulsions are time-consuming (e.g.take >1 h/d) or cause clinically significant

distress or impairment in social, occupational, or other important areas of functioning

C.the obsessive-compulsive symptoms are not attributable to the physiological effects

D.the disturbance is not better explained by the symptoms of another mental disorder

• specifiers:with good or fair insight, with poor insight, with absent insight/delusional beliefs, ticrelated

• most common obsessions:contamination fear, pathological doubts,harm (sex, aggression),somatic

dysfunctions, need for symmetry, religious

• most common compulsions:checking,washing,repeating,ordering,counting, need to ask, and

hoarding

• ritualsserve to counteract the anxiety induced by the obsessive thoughts

Epidemiology

• lifetime prevalence 3%

• mean age of onset:20 yr, onset after 35 yr rare

• rate of OCD in first-degree relatives is higher than in the general population

• common comorbidities: anxiety disorders(>75%), depressive or bipolar disorder (>60%), obsessivecompulsive PD,tic disorders,substance use disorder, body dysmorphic disorder,trichotillomania, and

excoriation disorder

Risk Factors

• etiology unknown but linked with:

neurological abnormalities: neurological dysfunction (brain injury,Sydenham’

s or Huntington’

s

chorea),abnormal EEG, and abnormal evoked auditory potentials

family history of OCD or '

l

'

ourette’

s disorder

paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection

(PANDAS) in children following group A p-streptococcal infection;also linked to D8/17 antigen

positivity

• social isolation, physical abuse, negative emotionality

Treatment

• CBT:ERP which involves exposure to feared situations using various techniques (e.g. imaginal

exposure,systematic desensitization, flooding) with the addition of preventing the compulsive

behaviours;cognitive strategies include challenging underlying beliefs

• pharmacotherapy:SSRls (12-16 wk potential delay until response,higher therapeutic dosages

than used for depression), clomipramine;adjunctive antipsychotics (risperidone, aripiprazole) for

refractor)

- OCD

• neurosurgery or neurostimulation: anterior cingulotomy forsevere refractory OCD, two techniques:

radiofrequency thermolesion and gamma knife capsulotomy or cingulotomy (50-70% response rate);

ECT (particularly for those with comorbid severe depression)

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Prognosis

• may be refractor)- and chronic with waxing and waning symptoms(<20% remission rate without

treatment)

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PS20 Psychiatry Toronto Notes 2023

Related Disorders

Body Dysmorphic Disorder

preoccupation with >1 perceived flaws in physical appearance not observed by others

repetitive behaviours(e.g. mirror checking, excessive grooming,skin picking, or reassurance seeking)

or mental acts (e.g. comparing self to others) related to appearance

± muscle dysmorphia

causes clinically significant distress or functional impairment

rule out eating disorder

mean age of onset:15 y/o

symptoms tend to be chronic; high rate ofsuicidal ideation and attempts; comorbidity with MDD,

social anxiety disorder, and OCD

treatment:SSRls,CBT (specific to body dysmorphic disorder)

Hoarding Disorder

• persistent difficulty discarding possessions regardless of actual value

• feels the need to save items,discarding creates distress

• results in possessions cluttering/compromising active living areas (may be uncluttered with 3rd party

intervention, i.e. family member, cleaners, authorities)

• causes clinically significant distress or functional impairment

• rule out brain injury, cerebrovascular disease, Prader-Willisyndrome,OCD, MDD (low energy),

psychotic disorder (delusions), neurocognitive disorder, ASD (restricted interests)

• tends to begin in teens and worsens over time, more common in older populations,large genetic

component

• treatment:CBT (specific to hoarding disorder)

Trichotillomania (Hair-Pulling Disorder)

• recurrent pulling out own hair resulting in hair loss (usually involvesscalp, eyebrows, or eyelashes but

may include other hair)

• repeated attempts to stop or decrease hair pulling

• causes clinically significant distress or functional impairment

• rule out dermatological condition, body dysmorphic disorder

• treatment:CBT (habit reversal training),SSRls, 2nd gen.antipsychotics, N-acetylcysteine, or lithium

Excoriation (Skin-Picking) Disorder

recurrent skin picking resulting in lesions

• repeated attemptsto stop or decrease skin picking

• causes clinically significant distress or functionalimpairment

• rule out scabies,substance use (e.g. cocaine), psychotic disorder (e.g.delusions, tactile hallucinations),

body dysmorphic disorder,stereotypic movement disorder, non-suicidal self-injury

• treatment similar to trichotillomania (described above)

Trauma- and Stressor-Related Disorders

Post-Traumatic Stress Disorder

DSM-5 DIAGNOSTIC CRITERIA FOR POST-TRAUMATIC STRESS DISORDER

Reprinted withpermissionIrom theDiagnostic andStatistical Manual of Mental Disorders.5th ed.2013.American Psychiatric Association.

A.exposure to actual or threatened death,serious injury,orsexual violence in one (or more) of the

following ways:

1. directly experiencing the traumatic event(s)

2. witnessing, in person,the event(s) as it occurred to others

3. learning that the traumatic event(s) occurred to a close family member or close friend; in

cases of actual or threatened death of a family member or friend, the event(s) must have been

violent or accidental

4. experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g.

first responders collecting human remains: police officers repeatedly exposed to details of

child abuse)

B.presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s),

beginning after the traumatic event(s) occurred:

1. recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)

2. recurrent distressing dreamsin which the content and/or affect of the dream are related to

the traumatic event(s)

3. dissociative reactions(e.g. flashbacks) in which the individual feels or acts as if the traumatic

event(s) were recurring

4. intense or prolonged psychological distress at exposure to internal or external cues that

symbolize or resemble an aspect of the traumatic cvent(s)

5. marked physiological reactions to internal or external cues that symbolize or resemble an

aspect of the traumatic event(s)

The Trauma Triangle

The perpetrator

The victim

The rescuer

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PS21 Psychiatry Toronto Notes 2023

C.persistent avoidance ofstimuli associated with the traumatic event(s), beginning after the traumatic

event(s) occurred, as evidenced by one or both of the following:

1. avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely

associated with the traumatic event(s)

2. avoidance of or efforts to avoid external reminders(people, places, conversations,activities,

objects,situations) that arouse distressing memories, thoughts, or feelings about or closely

associated with the traumatic event(s)

D.negative alterationsin cognitions and mood associated with the traumatic event(s), beginning or

worsening after the traumatic event(s) occurred,as evidenced by two (or more) of the following:

1. inability to remember an important aspect of the traumatic event(s)

2. persistent and exaggerated negative beliefs or expectations about oneself,others,or the world

3. persistent,distorted cognitions about the cause or consequences of the traumatic event(s) that

lead the individual to blame himself/herself or others

4. persistent negative emotionalstate (e.g.fear,horror, anger,guilt,orshame)

5. markedly diminished interest or participation in significant activities

6. feelings of detachment or estrangement from others

7. persistent inability to experience positive emotions

E.marked alterationsin arousal and reactivity'associated with the traumatic event(s),beginning or

worsening after the traumatic event(s) occurred,as evidenced by two (or more) of the following:

1. irritable behaviour and angry outbursts (with little or no provocation) typically expressed as

verbal or physical aggression toward people or objects

2. reckless orself-destructive behaviour

3. hypervigilance

4. exaggerated startle response

5. problems with concentration

6. sleep disturbance (e.g. difficulty falling or staying asleep or restlesssleep)

E duration of the disturbance (criteria B,C, D, and E) is more than 1 mo

G.the disturbance causes clinically significant distress or impairment in social, occupational,or other

important areas of functioning

H.the disturbance is not attributable to the physiological effects of a substance or another medical

condition

•specifiers:

with dissociative symptoms(not attributable to physiologic effects of a substance or a medical

condition):this could involve either depersonalization (persistent or recurrent experiences of

feeling detached from,or asifone were an outside observer of one’

s mental processesor body) or

derealization (persistent or recurrent experiences of unreality ofsurroundings)

with delayed expression:the full diagnostic criteria are not met until 6 mo after the event

Criteria for Post

-TraumaticStress

Disorder

TRAUMA

Traumatic event

Re-experience the event

Avoidance of stimuli associated with

the trauma

Unable tofunction

More than a Month

Arousal increased

- negative alterationsin cognition and

Epidemiology mood

•lifetime prevalence in Canada is9%;onset in mid-late 20s

•75% have another comorbid psychiatric disorder; increased risk ofsuicide 2-3x

•high rates of chronic pain,sleep problems,sexual dysfunction, cognitive dysfunction

•prevalence F:M=2:1

•most common forms of trauma: unexpected death of someone close,sexual assault,serious illness or

injury to someone close, physical assault by partner or caregiver

•risk factors:severity,duration,and proximity to trauma

•differential diagnosis:bipolar disorder, borderline personality disorder, acute stress disorder (3d-1 mo

after trauma)

Treatment

•trauma therapy,CBT

stage 1 -safety and stabilization:emotional regulation techniques (i.e.breathing, relaxation) to

help build copingskills,medicationsfor FI'

SD, manage substance use

stage 2 - remembrance and mourning:exposure to traumatic memories and work through

distorted thoughts,relational patterns,and grief

stage 3- reconnection and integration:exposure therapy, etc. create a new future, new

relationships,strengthen identity

•early intervention via psychologicalsupport (not de-briefing)

•psychotherapy:CBT, DBT,supportive, eye movement desensitization and reprocessing (EMDR)

•biological

• first line:fluoxetine, paroxetine,sertraline,venlafaxine XR (50-80% response with residual

symptomsis common)

prazosin (for treating disturbing dreams and nightmares)

benzodiazepines (for acute anxiety; use with extreme caution)

adjunctive atypical antipsychotics (risperidone, olanzapine)

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Prognosis and Complications

•substance use disorder, relationship difficulties, depression, impaired social and occupational

functioning disorders,personality disorders

•50% of patients with FI'

SD have complete recovery'within 3 mo,symptoms tend to diminish with age

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PS22 Psychiatry Toronto Notes 2023

Adjustment Disorder

Definition

• a diagnosis encompassing patients who have difficulty coping with a stressful life event or situation

and develop acute, often transient, emotional or behavioural symptomsthat resemble less severe

versions of other psychiatric conditions

Acute Stress Disorder

• May be a precursor to PTSO

• Similar symptoms to PISD

• Symptoms persist for 3d to1mo

after exposure to a trauma

DSM-5 DIAGNOSTIC CRITERIA FOR ADJUSTMENT DISORDER

Reprintedwithpermission from theDiagnostic andStatisticalManual of Mental Disorders.Sthed.2013.American Psychiatric Association

A.the development of emotional or behavioural symptomsin response to an identifiable stressorfs)

occurring within 3 mo of the onset of the stressor(s)

B.these symptoms or behaviours are clinically significant as evidenced by either of the following:

marked distressthat isin excess of what would be expected from exposure to the stressor

• significant impairment in social or occupational (academic) functioning

C.the stress-related disturbance does not meet criteria for another mental disorder and is not merely'an

exacerbation of a pre-existing mental disorder

D.the symptoms do not represent normal bereavement

h.once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an

additional 6 mo

• specifiers:with depressed mood,with anxiety, with mixed anxiety/depression, with conduct

disturbance,with mixed disturbance of conduct/emotions,unspecified

Classification

• types ofstressors

• single (e.g. termination of romantic relationship)

multiple (e.g. marked business difficulties and marital problems)

• recurrent (e.g.seasonal business crises)

continuous(e.g.living in a crime-ridden neighbourhood)

• developmental events(e.g.going to school, leaving parental home, getting married, becoming a

parent, failing to attain occupational goals, retirement)

Epidemiology

• FM=2:1,prevalence 2-8% of the population

Treatment

• brief psychotherapy:individualorgroup (particularly useful for patients dealing with unique and

specific medical issues; e.g.colostomy or renal dialysis groups), crisis intervention

• biological:medications can be used to treat associated symptoms (insomnia, anxiety, or depression)

benzodiazepines may be used for those with significant anxiety symptoms (short-term,low-dose,

regularschedule)

Bereavement

Clinical Features

• bereavement or grief is a reaction (involving thoughts,feelings,behaviours, and physiological

responses) to significant loss, typically the death of a loved one;mourning isthe process of integrating

and adapting to the loss

• length and characteristics of “normal"

bereavement vary between individual cultures

• normal response: protest 4 searching and acute anguish -» despair and detachment -> reorganization

• presence of the following symptoms may indicate abnormal grief/presence of MDD:

• guilt about things other than actions taken or not taken by the survivor at the time of death

thoughts of death other than the survivor feeling that they would be better off dead orshould

have died with the deceased person;morbid preoccupation w ith worthlessness

• marked psychomotor retardation; prolonged and marked functional impairment

• hallucinatory experiences other than hearing the voice or transiently seeing the image of the

deceased person

dysphoria that is pervasive and independent of thoughts or triggers of the deceased;absence of

mood reactivity

• after 12 mo, if patient continues to vearn/long for the deceased, experience intense sorrow/emotional

pain in response to the death, remain preoccupied with the deceased or with the circumstances of

their death, then may start to consider a diagnosis of “persistent complex bereavement disorder"

• if a patient meets criteria for MDD,even in the context of a loss or bereavement scenario, they are still

diagnosed with MDD

Risk Factorsfor Poor Bereavement

Outcome

• Poorsocialsupports

• Unanticipated death or lack of

preparation for death

• Highly dependent relationship with

deceased

• High initial distress

. Other concurrentstresses and losses

. Death of a child

• Pre-existing psychiatric disorders,

especially depression and separation

anxiety

Bereavement is associated with a

significant increase in morbidity and

mortality acutely following the loss,with

effectsseen up to1yr after

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Treatment

• support and watchful W'aiting should be first line, as well as education and normalization of the grief

process

• managementshould include assessment for secondary mental health or medical conditions,such as

PTSD, depression,suicidal ideation,increaased substance use,and cardiovascular illnesses

Loneliness is the most common

symptom that continuesto persist in

normal bereavement and may last

several years

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PS23 Psychiatry Toronto Notes 2023

• normal griefshould not be treated with antidepressant or anti-anxiety medications as it is important

to allow the person to experience the whole mourning process to achieve resolution

• psychosocial: grief therapy (individual or group) is indicated for those needing additional support or

experiencing complex grief/hereavement or significant MOD

• pharmacotherapy:if MOD present, past history of mood disorders,or severe symptoms

Neurocognitive Disorders s

Delirium

• see Neurology. N21

DSM-5 DIAGNOSTIC CRITERIA FOR DELIRIUM

Reprinted with permission Irom the Diagnostic and Statistical Manual ol Mental Disorders.Sth ed.2013.American Psychiatric Association

A.a disturbance in attention (i.e. reduced ability to direct, focus,sustain, and shift attention) and

awareness (i.e. reduced orientation to the environment)

B.the disturbance develops over a short period of time (usually hours to a few days), represents a change

from baseline attention and awareness,and tendsto fluctuate in severity during the course of a day

C.an additional disturbance in cognition (e.g. memory deficit,disorientation, language, visuospatial

ability, or perception)

D.the disturbances in criteria A and C are not better explained by another preexisting, established, or

evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal

(e.g. coma)

E.there is evidence from the history, physical exam, or laboratory findings that the disturbance is a

direct physiological consequence of another medical condition,substance intoxication or withdrawal

(i.e. due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies

Confusion Assessment Method (CAM)

for Diagnosis of Delirium

Highly sensitive and specific method to

diagnose delirium

Ftort1:an assessment instrument

thatscreensfor overall cognitive

impairment

Part 2:includesfour featuresfound

best able to distinguish delirium from

other cognitive impairments

Need (1) (2) (3or 4)

(1) Acute onset and fluctuating course

(2) Inattention

(3) Disorganized thinking

(4) Altered level of consciousness -

hyperactive or hypoactive Clinical Features

• common symptoms

• disturbance of attention: distractibility,disorientation (time, place, rarely person)

• sleep/wake disturbance (daytime sedation, nighttime agitation or wakefulness)

psychotic-like symptomssuch as delusions, misinterpretations, illusions,and hallucinations

(visual hallucinations are organic until proven otherwise)

affective symptoms (anxiety, fear, depression, irritability, anger, euphoria, apathy)

• shifts in psychomotor activity (groping/picking at clothes, attempts to get out of bed when unsafe,

sudden movements,sluggishness, lethargy)

• note:fluctuation/major changes in all of the above over the course of the day are to be expected - so

collateral history is important

• hyperactive 30% vs. hypoactive 24% vs.mixed level of activity 46%

(:»5

Etiology of Delirium

I WATCH DEATH

Infectious (encephalitis, meningitis,

urinary tract infection, pneumonia)

Withdrawal (alcohol, barbiturates,

benzodiazepines)

Acute metabolic disorder (electrolyte

imbalance,hepatic or renal failure)

Trauma (head injury, postoperative)

CNS pathology (stroke, hemorrhage,

tumour,seizure disorder,Parkinson'

s)

Hypoxia (anemia, cardiac failure,

pulmonary embolus)

Deficiencies (vitamin Bui, folic acid,

thiamine)

Endocrinopathies (thyroid, glucose,

parathyroid,adrenal)

Acute vascular(shock, vasculitis,

hypertensive encephalopathy)

Toxins:substance use,sedatives,

opioids (especially morphine),

anesthetics, anticholinergics,

anticonvulsants, dopaminergic agents,

steroids, insulin, glyburide, antibiotics

(especially quinolones), NSAIDs

Heavy metals(arsenic, lead, mercury)

Risk Factors

• a wide range of medical conditions can precipitate delirium in a susceptible individual and there may

be multiple underlying etiologies as a result

• polypharmacy particularly involving psychoactive drugs, anticholinergics, and serotonergic

medications (e.g.Cogentin, Benadryl*, benzodiazepines, opioids, and corticosteroids)

• infection,dehydration, malnutrition, immobility (including use of restraints),and use of bladder

catheters

• hospitalization (incidence 10-56%);frail and surgical patients are at the greatest risk

• previous delirium

• nursing home residents (incidence 60%)

• old age (especially males)

• severe illness(e.g. cancer, AIDS)

• recent anesthesia orsurgery (e.g. emergency hip fracture surgery, cardiac surgery)

• brain vulnerability:pre-existing neurologic or neurocognitive disorder,substance use disorder, past

psychiatric illness

Assessment

• observation:for disturbances in consciousness, incoherent and/or disorganized speech, inability to

concentrate upon conversation, disruption ofsleep-wake cycle

• history:often gathered from collateralsources as patients may be confused and/or uncooperative

• clinical instruments:Confusion Assessment Method (CAM) and formal mentalstatustesting,such as

the Mini-Mental State Examination, used as needed, are helpful for baseline and ongoing assessment

of altered mental state (i.e. score will improve assymptoms resolve)

• physical examination: may be difficult to perform; focus on vital signs, hydration status, potential

infectious foci, unambiguous neurologic deficits, and suggestive features of general appearance (e.g.

jaundice)

• medication review:drug toxicity accounts for approximately 30% of all delirium cases(including

OTC,non-prescribed medications)

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PS24 Psychiatry Toronto Notes 2023

Investigations

• standard bloodwork:CBC and differential,electrolytes(including Ca-% Mg-’, and PO-ti ),glucose,

BUN,Cr,TSH/T4, LFI'

s, vitamin Bi

’

,folate,albumin, toxicology screen;if indicated, order blood

cultures and infectiousserologies(HIV. VDRL, Hep B/C)

• standard imaging: CXR and CT head (indicated especially if focal neurological deficit, acute change in

status, anticoagulant use, acute incontinence,gait abnormality, Hx of cancer);if indicated, abdominal

x-ray for constipation and MK1 head to detect or exclude subacute stroke and multifocal inflammatory

lesionsin patients with negative headCT

• standard urinalysis: urine dip;if indicated, urine drug screen, urine C&S

- ifindicated;lumbar puncture and EEG (typical finding in delirium is generalized slowing,can also be

used to rule out underlying seizures or post-ictalstates as etiology')

Factors favouring psychosis over

delirium

t. Auditory hallucinations that are

structured and consistent

2. fersonal or family history of psychosis

3.Gradual onset (unless substance

induced)

4.History of a prodrome (insidious

functional decline)

Factors favouring delirium over

psychosis

1Visual or tactile hallucinations

2.Acute onset

3.No previous history of psychosis

4.Sleepwake changes

5. More global cognitive impairment

6. Recent medical illness/medication

changes

Management

• goal isto treat the underlying causes of delirium while minimizing the physical and psychological

distressto the patient

• step I:identify and manage underlying cause

identify and treat underlying cause immediately

stop all non-essential medications

maintain nutrition, hydration,electrolyte balance, and monitor vitals

work to ensure regular bowel movements and skin care practicesto present pressure ulcers

• step 2:optimize the environment

environment:quiet, well-lit, near window for cues regarding time of day

» optimize hearing and vision;protectsleep (with medicationsif need be)

room near nursing station for closer observation;constant care if patient climbing out of bed,

pulling out lines

• family member present (or consider 1:1 sitter) for reassurance and re-orientation

• frequent orientation: calendar,clock,reminders

• avoid frequent changes of assigned nursing staff as well as room transfers

implement falls prevention strategies and enable safe mobility

physical restraints to maintain safety only if necessary; minimize lines and catheters

calm,supportive approach; therapeutic communication

• step 3:pharmacotherapy

low dose, high potency antipsychotics:haloperidol has the most evidence and can be given IV or

1M;initiate Haldol* 0.5-1 mg IM/IV in elderly patients ql-2 h until agitation is under control for

STAT or PRN situation;0.5-2 mg PO q4-6 h - monitor forsigns of EPS and QT prolongation

alternativesinclude risperidone,which islesssedating (0.25-03mg PO BID;lesssedating),

olanzapine (more sedating, can be anticholinergic itself),quetiapine (if EPS sensitive but risk of

hypotension; 6.25-50 mg PO qHS),aripiprazole (does not prolong QTc)

caution:all neuroleptics prolong the QT interval and decrease seizure threshold, thus increasing

risk of cardiac arrhythmias and seizures,respectively; also, patients with Parkinson'

s disease or

Lewy body dementia are particularly at high-risk of EPS

ECG to assess QT interval when considering treatment with an antipsychotic agent

benzodiazepines only used in alcohol/substance withdrawal delirium;otherwise, can worsen

delirium (antipsychotics are not useful in EtOH or benzodiazepine withdrawal delirium);

however,benzodiazepinesshould not be stopped if they are a long-standing medication or this

may precipitate the delirium

try to minimize drugs with anticholinergic effects

• note:antipsychotic medications are used in delirium to treatsevere patient agitation, changing

delirium from the hyperactive to hvpoactive state; they do not treat the underlying “acute brain

state"

driving the delirium

iBtenmtmasfurPreventingDelirium in

Hosyitafizeit Non-ICU Patients

CnctraneDU Syst Rev 2016:00005563

Purpose:Is assess effectiveness of interventions

topretest ffeSnam inhospitalized patients in the

nos-lCll setting.

Methods:Hisstudy included RCTs on both

phamacologitaland non-pharmacological

mtemectrons for delirium in hospitalized patients in

theoos-lCtl setting.

lesults:iff t-als involving1(082 patients assessing

22 Afferent isterreetions wereincluded.Strong

entente was identifiedInsupport theuse of

nlb-coapoaent interventions for the prevention

of deism.Ibltcomponeiit interventions include

ay utervention that uses nun-pharmacological

approaches to target multiple risk factors for

deirn.Use of die(.spectral index to monitor

acesres a reduced incidence of postoperative

deirwa.hidenee tn date dues not support the

use af cci-esterase inhibitors,antipsychotics.or

metetosia toreduce incidence of delirium.

Prognosis

• up to 50% I yr mortality rate after episode of delirium

Major Neurocognitive Disorder (Dementia)

• see Neurology, N22

DSM-5 DIAGNOSTIC CRITERIA FOR MAJOR NEUROCOGNITIVE DISORDER

Reprinted withpermission from theDiagnostic andStatisticalManual of Mental Disorders,Slh ed.2013.AmericanPsychiatricAssociation

A.evidence ofsignificant cognitive decline from a previouslevel of performance in one or more cognitive

domains(complex attention, executive function,learning and memory,language, perceptual-motor,

orsocial cognition) based on

1. concern of the individual,a knowledgeable informant,or the clinician that there has been a

significant decline in cognitive function;

and

2. a substantial impairment in cognitive performance, preferably documented by standardized

neuropsychological testing or,in its absence, another quantified clinical assessment

B.the cognitive deficits interfere with independence in everyday activities(i.e.at a minimum, requiring

assistance with complex IADLS such as paring bills or managing medications)

Cthe cognitive deficits do not occur exclusively in the context of a delirium

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