急診讀書會 2024/02/29 導讀：R1 莊宇婕／指導：VS 林月屏

Chapter 8 The cognitively impaired patient

✓ Why important?
 Many discrete psychiatric illnesses are associated with cognitive
impairment. →differential diagnosis is broad.
 Prompt assessment requires an integrative approach→ clinical history,
clinical examination, neuroimaging, clinical laboratory testing, physical
examination, ECG, EEG.
 Clinical disposition of patients with cognitive impairment may be quite
varied.

 在急診的 setting 通常不⼀定能做到診斷以及 long-term management，

但初步評估以及介入很重要
✓ Evaluation of the patient

 Safety and restraint: 為了保護病⼈有時候在做出⼀個診斷前就需要先

考慮 seclude, restrain and medicate disruptive patients

 Workup: graphic illustration of the integrative biopsychosocial approach
Examination: history taking (collateral history), PE, MSE, cognitive
screening tests (MMSE, MoCA, Clock drawing, Mini-Cog,
Confusion Assessment Method), Executive function (Frontal
Assessment Battery)
Laboratory assessment: The acute presentation of cognitive
impairment often represents overlapping syndromes of delirium and
major or mild neurocognitive disorders (NCDs)

Neuroimaging: For most emergency purposes, CT is easier to obtain,

lower cost, easier for the patient to tolerate, and not subject to patient
contraindications.
 EEG and Lumbar puncture: EEG may be helpful in differentiating
between delirium and NCDs, but is not as useful in sub-typing of
delirium. Lumbar puncture is considered if there is high suspicion of
CNS infections
✓ Psychiatric disorders characterized by cognitive impairment:
 The majority of patients who present with cognitive impairment in the
emergency setting will have an illness classified in DSM-5 among the
NCDs.
 Classified into major and minor NCDs (差在 cognitive decline and
functional impairment 的程度)
 Subclassification according to neuropathological cause
 A smaller percentage of patients will have illness classified in DSM-5
among the neurodevelopmental disorders
✓ Delirium: DSM-5 subacute to acute onset condition characterized by
disturbance in attention and awareness, circadian disturbances, cognitive
impairment
 Variable cause, systemic disturbances, preexisting major or minor NCDs
→ takes thorough clinical search

 Prompt treatment is important for minimizing suffering and maximizing

safety
 Delirium superimposed on major or mild NCD:可能原本的 NCD 沒有被
治療
 Neuroleptic malignant syndrome: delirium, rigidity and increased CPK
management requires supportive care, withholding of antipsychotics until
CPK renormalized for at least 2 weeks
✓ Major or mild NCD: DSM-5 define from a previous level of performance in
one or more cognitive domains, not solely due to delirium or another
psychiatric illness
 Distinguishing from delirium: full alertness
 Can be quite rapidly progressive or may be reversible with clinical
intervention
 Associated with a range of other psychiatric comorbid condition (ex.
Depression, psychosis such as delusion and hallucinations)
 Sundowning phenomenon: confusion and motor agitation in the evening
and at night
 The presentation to emergency may be due to social factors rather than
clinical ones
 Major or mild NCD due to Alzheimer’s disease
The most common subtype in western societies
Generally after age 65
Clinically present with amnesia and various other cognitive deficits
(disorientation, aphasia, anomia, apraxia, disturbed executive
function)
來急診通常是因為自理功能下降或其他 psychiatric comorbidity
 Major or mild vascular NCD
Results from CNS infarction
Patients with multiple vascular risk factors: hyperlipidemia,
hypertension, smoking, and/or diabetes mellitus
Pattern of cognitive deficits may resemble those in NCD due to
Alzheimer’s disease, 但 vascular NCD 的發展通常是 occasional
abrupt losses in cognitive function
 Major or mild NCD with Lewy bodies
Younger age at onset
More rapidly progressive course
Fluctuations in mental status
Early-onset and clinically prominent hallucinations (typically visual)
 Major or minor frontotemporal NCD
Frontal lobe deficit-related decrements in appropriate social behavior
with relatively preserved memory function
Disruptive social behavior: sexual inappropriateness, impulsivity,
emotional dysregulation
評估的時候可能會觀察到 frontal lobe deficit，but preserved
cognitive examination (MMSE in non-impaired range)
 Major or mild NCD due to HIV infection
May result from direct effects of the HIV virus on CNS
HIV patients 有出現新發生的 neurocognitive impairment 都要考慮
這個病因
 Aggressive treatment with highly active antiretroviral therapy agents
can result on some reversibility of neurocognitive symptoms
 Major or mild NCD due to traumatic brain injury
Period of unconsciousness, degree of post traumatic amnesia,
cognitive status at the time of evaluation
初期可能比較像 Delirium，但時間久了還有症狀可能是 major or
mild NCD
 Major or mild NCD due to other neurodegenerative illness
Parkinson’s disease, Huntington’s disease, multiple sclerosis
✓ Parkinson’s disease, Huntington’s disease, multiple sclerosis
 Transient global amnesia
An acute-onset global amnesia that is reversible
Middle aged patients with no prior psychiatric history
Cause is unclear, may be a temporary disturbance in temporal lobe
function
 Korsakoff syndrome
Acute-onset amnestic disorder in the context of alcohol dependence
Thiamine deficiency -> treatment with IV thiamine
 Carbon monoxide poisoning
May result in focal hippocampal injury and thus amnesia in the
absence of more global cognitive impairment
 Dissociative amnesia
Acutely amnestic patient who has experienced a psychologically
troubling or event traumatic event and defends against this reality
with dissociative defense
 Subdural hematoma or subarachnoid hemorrhage
Associated with head trauma or untreated hypertension
May present with acute delirium, progressive major or mild NCD, or
combination of both
 Alcohol and/or drug disorders
Intoxication or withdrawal 都有可能
 Depressive pseudo-dementia
Overlap of mood and cognitive function, usually seen in older
patients

Treatments: antidepressant, 治療⼀段時間後可以重新評估認知功

能
✓ Childhood-onset syndromes characterized by cognitive impairment: Increased
 risk of major or mild NCD as they aged
 Intellectual disability
 Down syndrome
 Fragile X disorder
 Fetal alcohol syndrome
✓ Clinical management
 Treatment
First step: management of systemic factors
Psychotropic medications are in common use to treat behavioral
symptoms
Antipsychotics: 急診最常用 haloperidol
BZD alone: delirium due to alcohol or sedative-hypnotic withdrawal
BZD combined with antipsychotics: delirium due to other cause
Anticonvulsants: control agitation
Anesthetic agents: dangerous agitation cases
任何用來 control agitation 的治療都有可能造成 delirium，因此要
小心使用
 Disposition

 Legal issues in cognitive impairment