Geropsychiatry: Delirium and Dementia

Geropsychiatry: Delirium and Dementia
By:Robert Averbuch, MD
Assistant Professor
Department of Psychiatry

Disorders of Cognition
* DSM-IV devotes an entire section to a subset of “organic” disorders that primarily affect cognition: “Delirium, Dementia, and Amnestic and other Cognitive Disorders”

What is “organic”?
* Previous differentiation between mental disorders with a clear “physical or biological” etiology (Organic) and those without (“Functional” or “Primary”)
* Falsely implied that Functional (or primary) disorders have no underlying pathophysiological basis
* Primary mental disorder- not due to a GMC or substance

Disorders of Cognition
* Delirium-disturbance in consciousness and cognition that develops rapidly
* Dementia- multiple cognitive deficits that include memory disturbance
* Amnestic Disorder- primarily memory impairment

Delirium
Delirium: defined
* Disturbance of consciousness (awareness of the environment) and attention,
* PLUS…
o Changes in cognition (ie, “thinking”-memory, orientation, language, etc) OR
o Perceptual disturbances

The Course of Delirium
* Evolves rapidly (hrs to days)
* Usually resolves rapidly as well:
o May be self-limited, persist for weeks, or progress to death
* Degree of impairment fluctuates

Delirium: Associated Features
* Disturbance in sleep-wake cycle
* Easily distracted by irrelevant stimuli
* Changes in activity level
o Restlessness, hyperactivity
o Picking at clothes, getting out of bed
o OR hypoactivity (lethargy)
* Emotional disturbances- mood lability, anger, irritability, euphoria, apathy

Delirium: Associated Features
* Speech or language disturbances
* Perceptual abnormalities- common:
o Illusions, hallucinations, delusions
* Neurological deficits/dysfunction

What Are the Causes?
* DIRECT: Brain pathology: head injury, seizures (during and after), strokes, infections
* INDIRECT: Systemic Illness: electrolyte abnormalities, dehydration, uremia, hepatic encephalopathy, cardiovascular compromise

More Causes of Delirium
* Sensory deprivation
* After surgery (post-operative state)- ie. “ICU Psychosis”
* Side effects of medications or toxins or with abused recreational drugs:
“Substance-Induced Delirium”
o Ex. NMS (Neuroleptic Malignant Syndrome)
o Ex. Serotonin Syndrome

Treating Delirium
* Considered a Medical Emergency
* Supportive care in an ICU setting
* Safety- close monitoring
* Remove offending agent, treat underlying cause

Dementia
Hallmark is Memory Impairment
* Memory problems usually evident early
* Memory impairment alone is not enough to make the diagnosis…

Dementia- defined
* Memory problems AND at least one additional cognitive deficit:
o Aphasia
o Apraxia
o Agnosia
o Problems with “executive functioning”

Details, Details: Aphasia
* Aphasia is a drop off in language function that shows up in a variety of ways

Apraxia
* “impaired ability to pantomime the use of known objects or to execute known motor acts”

Agnosia
* Trouble recognizing or identifying things despite intact sensations (ex. You can see fine, but you can’t recognize a stop sign)
* May include difficulty recognizing family members or even themselves in the mirror

Disturbances in Executive Functioning
* Abstract thinking
* Planning, initiating, sequencing, and stopping behaviors
* May manifest as trouble with novel tasks or new situations

Associated Features
* Spatial disorientation
* Poor insight and judgment means…they get themselves in trouble by overestimating their abilities and underestimating risks
* Perceptual Abnormalities:
o Delusions- especially persecution
o Hallucinations- especially visual

More associated features
* Personality Changes:
o Disinhibition
o Neglect of personal hygiene
o Apathy and withdrawal

Course of Dementia
* Course may be progressive, static, or remitting
* Small percentage of cases are reversible

What causes Dementia?
* Alzheimer’s is by far the most common type
* Cerebrovascular Disease
* Degenerative Diseases: Parkinson’s, Huntington’s, CJD (Mad Cow Disease)

More causes:
* Autoimmune Illness
o Lupus
o Multiple Sclerosis
* B12, Folate Deficiencies
* Head Trauma, Brain Tumors
* Infections- like HIV and Syphilis

Alzheimer’s
Dementia of the Alzheimer’s Type (DAT)
* Diagnosis of exclusion
* Hallmark: gradual onset of recent memory problems
* Onset may be early (65 y/o or younger) or Late (over 65)

DAT
* Slowly progressive (8-10 years from diagnosis to death)
* Many show personality changes
* Often with associated behavioral disturbances (wandering, agitation, etc.)

Vascular Dementia
Aka Multi-Infarct Dementia
Vascular Dementia
* Evidence of cerebrovascular disease on physical exam and head scans
* Usually caused by several strokes over time
* Onset abrupt, followed by stepwise, fluctuating course with “patchy” deficits

Treatment of Dementia
* Search for a reversible cause and treat (ex. B12 deficiency, Normal Pressure Hydrocephalus, Syphilis, etc)
* Rule out Pseudodementia (change in cognition associated with depression)
* Environmental/behavioral interventions- ex. no fail environment
* Medications

Medications
* Cholinesterase Inhibitors:
o Aricept (donepezil)
o Reminyl (galantamine)
o Exelon (rivastigmine)

Medications
* NMDA-receptor antagonists
o Namenda (memantine)
o Neuroprotective by blocking excessive glutamate stimulation of the NMDA (N-methyl-D-aspartate) receptor

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Warts Diagnosis and Treatment

Warts Diagnosis and Treatment
By:Rick Lin, DO MPH
Texas Division of KCOM Dermatology Residency Program

Background Information
* Warts are small harmless lesions of the skin
* caused by a virus: the human papilloma virus.
* The appearance of warts can differ based on the type of wart and where it is located on the body.
* Warts are common in children. Most cases occur between ages 12-16 years.
* Up to 30% of warts disappear by themselves within 6 months. Most will disappear without any treatment within 3 years.
* Warts are caused by the DNA-containing human papillomavirus (HPV). There are at least 63 genetically different types of HPVs.
* The virus enters the skin after direct contact with recently shed viruses kept alive in warm, moist environments such as a locker room, or by direct contact with an infected person.
* The entry site is often an area of recent injury. The incubation time—from when the virus is contracted until a wart appears—can be 1-8 months.
* Contrary to popular mythology, touching a frog will not give you warts.

Types of warts
* Common warts (verrucae vulgaris): These common warts typically develop on the hand, especially around the nail. They are gray to flesh colored, raised from the skin surface, and covered with rough, hornlike projections.
* Plantar warts (verrucae plantaris): Plantar warts, by definition, occur on the plantar surface, or bottom, of the foot.
* They usually occur in high pressure areas such as the heel and the metatarsal heads (just behind the toes).
* They usually grow into the skin, not outward like common warts.
* This growing into the skin makes them more difficult to treat.
* Flat warts (verrucae plana): Flat warts are most commonly seen on the face, the back of the hands, and lower legs.
* They usually appear as small individual bumps about 1/4 inch across.
* Flat warts may spread rapidly on the face and lower legs from the activities involved in shaving.

Histopathology
* Verruca vulgaris (common wart) is caused by varous strains of human papilloma virus (HPV 1, 2, 4, 7, 26-29).
* Macroscopically verruca vulgaris may present as hard, rough surfaced papule
2 – 20 mm (solitary or multiple).
* Microscopically, this is an exophytic, symmetric, papillomatous lesion with large keratohyaline granules and characteristic inturning of the rete ridges.

Histopathology
* Parakeratotic columnar tiers of stratum corneum overlie the papillomatous surface.
* Small amounts of hemorrhage may be present within the columns of parakeratosis.
* Other characteristic features include koilocytosis, hypergranulosis and presence of multinucleated cells.

Treatment
* Home care is effective in making the wart or warts go away. No matter what technique you use, warts will disappear 60-70% of the time.
* Techniques may be done with and without medication.
* The ultimate goal of the medical therapies (not the surgical treatments) is to get your body to recognize the wart as something foreign and to destroy it, much like the body destroys a cold virus.

Adhesive tape therapy
* Place several layers of waterproof adhesive tape over the wart region (even duct tape).
* Do not remove the tape for 6-1/2 days. Then take off the tape and open the area to the air for 12 hours.
* Reapply tape for another 6-1/2 days.
* The tape works best in the region around the fingernail.
* Tape works because the air-tight, moist environment under the tape does not allow the virus to grow and reproduce

Salicylic acid therapy
* Salicylic acid is available by many different trade names at the drug store.
o Dual Film
o Wart-Off
o Dr. Scholl’s Wart Medication
o Medi-Plast
* It comes either as a liquid to paint on the wart or as a plaster to be cut out and placed on the wart tissue.
* The area with the wart should be soaked in warm water for 5-10 minutes.
* The wart should then be pared down with a razor. A simple razor works fine for this, then throw it away.
* Do not shave far enough to make the wart bleed.
* Apply the salicylic acid preparation to the wart tissue.
* Do not apply it to other skin because of salicylic acid's potential to injure normal tissue.
* Follow directions on the package for how long to apply the acid.

Cryosurgery
* Liquid nitrogen or cryotherapy is used to deep freeze the wart tissue.
* With liquid nitrogen applied to the wart, the water in the cells expands, thus exploding the infected tissue.
* The exploded cells can no longer hide the human papillomavirus from the body's immune system.
* The immune system then works to destroy the virus particles.
* Periungual area may scar if cryotherapy with liquid nitrogen is used improperly.
* Scarring could lead to permanent nail disfiguration.

Laser Therapy
* Laser therapy: Lasers are simply very intense light sources.
* This light has an enormous amount of energy that heats the tissue enough that it vaporizes.

Shave Removal
* Shave removal and electrodessication of the base may be necessary when other treatment methods fail.
* This would involve numbing the region around the wart and shaving the wart flat with the surface and light electrodessication of the base.

Prognosis:
* Most warts will disappear without treatment anywhere from 6 months to 3 years.
* Warts may recur after treatment and require additional treatments.
Prevention:
* Avoid touching warts on others or touching them on yourself (refrain from rubbing a warty finger across your face).
* Children needs to avoid biting or chewing warts.
* Wear shower shoes in the gym locker room to lower your risk of picking up the virus that causes plantar warts from the moist environment.

When to Refer
* If you feel uncomfortable treating warts.
* Warts that are resistant to your treatment
* Unsure of diagnosis

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Dermal and Subcutaneous Tumors

Dermal and Subcutaneous Tumors

Mastocytosis
Urticaria pigmentosa
* Local and systemic accumulations of mast cells
* Persistent pigmented itchy skin lesions
* Urticate on mechanical or chemical irritation
* c-KIT mutation
* Birth to middle age, ½ < 6 mo
* Macules, papules, nodules, plaques, vesicles
* Lesions persist and gradually become chamois- or slate-colored
* Darier’s sign, pruritis
* Severe symptoms may result from massive liberation of histamine from mast cells after ingestion of known mast cell degranulators
* Spontaneous resolution is likely in those pts whose disease began in childhood

Solitary mastocytoma
* May be present at birth, may develop during the first weeks of life
* Brown macule that urticates upon stroking
* Smooth or peau d’ orange
* Dorsum of the hand near the wrist
* Edema, urtication, vesiculation may be observed
* Generalized eruption, childhood type
* Pseudoxanthomatous mastocytosis
* Diffuse cutaneous mastocytosis
* Generalized eruption, adult type
* Erythrodermic mastocytosis
* Telangiectasia macularis erupta perstans
* Systemic mastocytosis
* Familial urticaria pigmentosa
* Giemsa, azure A, or polychrome toluidine blue
* Local anesthetic adjacent to the lesion, without epi
* Dx is bx confirmed
* Histamine metabolites methylhistamine and methylimidazole acetic acid

Prognosis and treatment
* In all forms without systemic involvement the prognosis is good
* Solitary lesions usually involute within 3 years
* H1 and H2 blockers
* PUVA
* Intralesional and topical steroids
* Avoid physical stimuli

Abnormalities of neural tissue
Solitary neurofibroma
* Soft, flaccid, pinkish white, 2-20 mm
* Invaginates on pressure, “buttonholing”
* Solitary or multiple
* Distinctive histopathologic findings, fibrils, cellular proliferation, and degenerative changes
* Sx excision

Granular cell tumor
* Well-circumscribed, solitary firm nodule, with a brownish red or flesh tint
* Usually solitary, 10-15 % multiple
* 1/3 of cases have occurred on the tongue
* May occur anywhere on the body
* Grows slowly
* Cells stain positively with vimentin, neuron-specific enolase, S-100, and myelin protein
* Malignant granular cell tumor is rare

Neuroma cutis
* Three true neuromas exist in the skin and mucous membranes: traumatic neuroma, multiple mucosal neuromas, and solitary palisaded encapsulated neuromas
* Traumatic neuromas occur commonly on the fingers, tender and painful
* Multiple mucosal neuromas occur as part of multiple mucosal neuroma syndrome
* solitary palisaded encapsulated neuromas occur commonly on the face, resembles BCC

neurothekeoma
* Nerve sheath myxoma
* Benign tumor of nerve sheath
* Mitotic figures and nuclear atypia are sometimes observed
* Intradermal or subcutaneous
* Histologically are divided into two subtypes: myxoid and more common cellular variant

schwannoma
* neurilemmoma
* Usually a solitary nerve sheath tumor
* Most often seen in women
* Occur almost exclusively along the main nerve trunks of the extremities
* Soft or firm nodules, may be painful
* May be multiple
* May be assoc. with NF-1 or NF-2
* Occur in many other organs
* excision

Infantile neuroblastoma
* The most common malignant tumor of childhood
* Cutaneous nodule are most often seen in the younger patients
* Blue nodules the when rubbed form a halo of erythema
* Periorbital ecchymoses and heterechromia
* Good prognosis for patients with skin involvement, spontaneous remission

ganglioneuroma
* Rarely described in the skin as an isolated entity
* Arise most often in von Recklinghausen’s neurofibromatosis
* Occur in childhood

Nasal glioma
* Cephalic brainlike heterotopias
* Rare, benign congenital tumors
* Easily confused with hemangiomas
* Firm, reddish blue lesion on the nasal bridge
* No connection with the subarachnoid space
* Radiography and neurosurgical consultation
* Does not involute spontaneously

Cutaneous memingioma
* Psammoma
* Results from the presence of meningocytes outside the calvarium
* Small, hard, fibrous, calcified nodules occurring along the spine, in the scalp, and on the forehead
* Usually seen within the first year
* No distinctive appearance, dx by histo

Encephalocele and Meningocele
* Primary defect in the neural tube
* Present in infancy along the midline
* Compressible masses that may transilluminate or enlarge with crying
* Midline masses require intensive radiologic and neurosurgical evaluation before biopsy

chordomas
* Slow-growing, locally invasive
* Firm, smooth nodules in the sacralcoccygeal region or at the base of the skull
* Arise from notochord remnants
* May metastasize late in their course
* Wide excision and postoperative radiation therapy

Abnormalities of Fat Tissue
lipomas
* Subcutaneous tumors composed of fat tissue
* Most commonly found on the trunk
* Also neck, forearms and axillae
* Soft, single or multiple, lobulated and compressible
* Growth to size and remain stationary
* again be careful of sacrococcygeal lipomas
* Lesion may be left untreated or excised
* Solitary lesions reaching greater than 10 cm should be investigated for malignancy
* Multiple lesion may be painful if growing rapidly
* Madelung’s disease, benign symmetric lipomatosis
* Dercum’s disease, assoc with weakness and psychiatric disturbances
* Familial multiple lipomatosis, AD inheritance
* Bannayan-Riley-Ruvalcaba syndrome
* MEN 1
* Frohlich’s syndrome
* Gardner’s syndrome

angiolipoma
* A painful subcutaneous nodule just slightly above the level of the skin
* Has all other typical features of a lipoma
* Seen in young adults who have multiple painful lumps in the skin
* Multiple subcutaneous angiolipomas have no invasive or metastatic potential

Neural fibrolipoma
* Overgrowth of fibro-fatty tissue
* Occurs along a nerve trunk and often leads to compression
* Slowly enlarging subcutaneous mass with tenderness and decreased sensation or parasthesia
* Median nerve is most commonly involved
* MRI, no effective treatment

Spindle-cell lipoma
* Asymptomatic, slow growing subcutaeneous tumor
* Predilection for the back and neck and shoulders of older men
* Consists of lobulated masses of mature adipose tissue

Painful Piezogenic pedal papules
* Transitory, soft, sometimes painful papules on the sides of the heels
* Elicited by weight-bearing and disappearing when this is stopped
* Occur in at least 75 % of normal individuals
* Suitable supportive shoes may alleviate discomfort
* May occur on the wrist

Nevus lipomatosus superficialis
* Soft, yellowish papule or ceribriform plaques, usually of the buttock or thigh, less often the ear or scalp
* A wrinkled surface characterizes this tumor
* Onset prior to age of 20
* Nevus lipomatosus superficialis

Folded skin with scarring
* Rare, aka Michelin Tire Baby Syndrome
* There are numerous deep, conspicuous, symmetrical, ringed creases around the extremities
* The underlying skin may manifest a smooth muscle hamartoma, a nevus lipomatosis, or elastic tissue abnormalities
* AD, sporadic or an isolated finding assoc with congenital facial and limb abnormalities

Diffuse lipomatosis
* Characterized by an early age of onset, by the age of 2, diffuse infiltration of muscle by and encapsulated mass of mature lipocytes
* Progressive enlargement and extension
* Usually involves a large portion of the trunk or extremity

Hibernoma
(lipoma of brown fat)
* A form of lipoma composed of finely vacuolated fat cells of embryonic type
* Have a distinctive brownish color and a firm consistency
* Benign and usually occur singly
* Chiefly in the mediastinum and the interscapular region
* Onset usually in adult life

Pleomorphic lipoma
* Occur for the most part on the backs and necks of elderly men
* Occasional lipoblast-like cells and atypical mitotic figures may require differentiation from a liposarcoma
* Behave in a perfectly benign manner`

Benign lipoblastomatosis
* Frequently confused with a liposarcoma
* Affects exclusively infants and young children, 90% < age 3
* Commonly involves the soft tissues of the upper or lower extremity
* A circumscribed and a diffuse form can be distinguished
* TOC- complete local excision

liposarcoma
* One of the less common mesenchymal neoplasms of the soft tissue
* Usually arise from intermuscular fascia
* Do not arise from preexisting lipomas
* Usual course is an inconspicuous swelling of the soft tissue with gradual enlargement
* When a fatty tumor becomes greater than 10 cm DX should be considered
* Upper thigh is the most common site
* Adult males are mostly affected
* May be well or poorly differentiated
* Tx is adequate radical excision
* For metastatic liposarcomas, radiation therapy may be effective

Abnormalities of smooth muscle
leiomyoma
* Smooth muscle tumors
* Characterized by painful nodules
* Singly or multiple
* Benign
* Treatment is directed toward the removal of the pain source
* Simple excision is best
* Solitary cutaneous leiomyoma
* Multiple cutaneous leiomyomas
* Solitary genital leiomyoma
* angioleiomyoma

Grouped leiomyomata of the back
Congenital smooth muscle hamartoma
* Typically a skin colored or slightly pigmented patch or plaque with hypertrichosis
* Often present at birth
* Usually seen on the trunk, lumbosacral area in 2/3
* Michelin tire baby syndrome may result from a diffuse smooth muscle hamartoma
* Clinically may mimic a mastocytoma, pseudo-Darier’s sign is seen in 80%
* No treatment is necessary

leiomyosarcoma
* Of soft tissue origin are extremely rare
* May occur as metastasis from internal source
* Appears in the dermis as a solitary nodule, good prognosis
* Subcutaneous lesions have a guarded prognosis, with fatal hematogenous metastases in 1/3
* WLE or Mohs

Miscellaneous tumors and tumor-associated conditions
Cutaneous endometriosis
* Brownish papules in the umbilicus or lower abdominal scars after gynecologic surgery
* Tender or painful lesions
* Bluish black from cyclic bleeding
* Usually misdiagnosed as malignant metastases
* Surgical excision
* Preoperative tx with danazol or leuprolide may reduce size

teratoma
* May develop in the skin but are most common in the ovaries or testes
* No characteristic clinical features
* Tissue representing all three germ layers are present
* Occasionally malignancy may occur

Metastatic carcinoma
* 5 to 10% of patients with cancer develop skin metastases
* Usually present as numerous firm, hard, or rubbery masses
* Predilection for chest, abdomen or scalp
* Sister Mary Joseph nodule, metastatic tumor localized to the umbilicus, most common primary sites include the stomach, large bowel, ovary and pancreas
* A poor prognosis is usually the rule
* The involvement of the skin is likely to be near the area of the primary tumor
* Breast cancer is the type most commonly metastatic to the skin in women and melanoma followed by lung cancer in men
* Metastatic lesions are uncommon in children

Paraneoplastic syndromes
* Some cancers produce findings in the skin that indicate to the clinician that an underlying internal malignancy may be present
* Bazex’s syndrome, characterized by violaceous erythema and scaling of the fingers, toes, nose, and aural helices.
* Secondary to a primary malignant neoplasm of the upper aerodigestive tract

Bazex’s syndrome
* Necrolytic migratory erythema, seen with glucagon-secreting tumors of the pancreas
* Erythema gyratum repens, erythema with characteristic wood-grain-pattern scales, is almost always associated with and underlying malignancy
* Hypertrichosis lanuginosa aquisata, most common with lung and colon ca
EGR
Hypertrichosis lanuginosa
* The sign of Lesser-Trelat, the sudden appearance of multiple pruritic seborrheic keratosis, associated with and internal malignancy
* Trousseau’s sign, migratory thrombophlebitis, pancreatic ca
* Pityriasis rotunda
* Tripe palms
* Several others with less frequency

carcinoid
* Characterized by distinctive involvement of the lungs, heart, gastrointestinal tract and the skin
* Cutaneous flushing lasting 5-10 minutes
* Involves the head and neck producing a scarlet color
* Cyanosis may be present
* Episodic flushing continues for months or years
* The release of excessive amounts of serotonin and bradykinen into circulation produces attacks of flushing of the skin, weakness, abdominal pain, nausea and vomiting, sweating, palpitation, diarrhea and collapse
* Tumor arises from the argentaffin Kulchitsky chromaffin cells of the appendix or terminal ileum (gi, lungs, ovaries, testes)
* The diagnosis may be established by finding high levels of 5-hydroxyindolacetic acid (5-HIAA) in the urine
* Tx- primary tumor should be removed, and excision of metastatic lesion should be considered
* Chemotherapy

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