Authors: Flaherty, Alice W.; Rost, Natalia S.
Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition
Copyright 2007 Lippincott Williams & Wilkins
> Table of Contents > Adult Neurology > Encephalopathy, Delirium, and Dementia
Encephalopathy, Delirium, and Dementia
A. See also
B. Management of agitation
1. Acute : See Psychiatric emergencies, p. 97 .
: Risperidone (less sedating) or quetiapine (less risk of movement
Agitated confusion, usually with the
: Hypoxia, hypercapnia, electrolytes,
2. Tests : Consider head CT, ABG, EKG, electrolytes, BUN, Cr, Ca, ammonia, toxin screen, CBC, ESR, U/A and other infectious workup, LP, EEG.
1. Reversible causes of subacute or chronic encephalopathy :
a. The big two
: Addiction (
), pseudodementia of depression/anxiety (
). Ask family
: Bilateral SDH, NPH, vasculitis, lymphoma, metabolic, tumor (
2. Creutzfeldt-Jakob dz (CJD)
a. H&P : Variable combinations of myoclonus, dementia, and ataxia; progresses to death in weeks to 2 yrs. BSE more often begins with psychiatric symptoms.
b. Incidence : Peaks in late 60s for sporadic form, about age 30 for BSE.
c. Tests : Brain biopsy shows spongiform encephalopathy. EEG shows diffuse periodic sharps. MRI shows characteristic DWI changes in the caudate, putamen, and cortical ribbon. CSF has 14-3-3 protein (also high in encephalitis and some gliomas). Brain biopsy shows spongiform encephalopathy.
: CJD is transmissible only when infected neural
Chronic selective loss of ‰2 higher cortical functions, especially memory and naming. Pt. may be disoriented acutely at night, but frank hallucinations are rare.
: Education, baseline personality, ADLs,
2. Tests : Head CT, CHEM10, CBC, VDRL, ESR, TSH, B 12 . Consider HIV test, LP, EEG, heavy metal screen, brain biopsy.
3. Potentially reversible causes : See Encephalopathy, above.
4. Normal pressure hydrocephalus (NPH) :
: Frontal gait, incontinence (from abulia or not being able to get to bathroom), dementia (
: Serial large-volume LPs (not
c. Rx of NPH
: Ventriculoperitoneal shunt. Gait apraxia responds best; dementia worst, especially if longstanding. Risk of SDH (vessels already
5. Irreversible causes :
a. Alzheimer's dz (AD)
: Usually with
b. Lewy body dz : More episodic delirium, psychiatric features (visual hallucinations, depression), and extrapyramidal features than AD. May benefit from low-dose levodopa or a dopamine agonist in combination with an atypical neuroleptic (e.g., quetiapine). Avoid typical neuroleptics.
c. Frontotemporal dementia (A tauopathy, formerly Pick's disease): More personality change, less aphasia or amnesia than AD.
d. Cortical vs. subcortical dementia : Latter is more manageable because pt has insight, can use cueing and to-do lists. Often associated with executive dysfunction.
Table 8. Cortical vs. subcortical dementia .
e. Mixed : Lewy body disease, Multi-infarct dementia, CJD, MS.
f. Rx : Social services, treat depression (avoid TCAs), neuroleptics such as haloperidol (see Delirium above re black box warnings), or short-acting benzodiazepines for agitation. Consider donepezil (a cholinergic agonist) or memantine (an NMDA antagonist).