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Geriatrics
Insanities
Courses of Geriatrics
 


 

Definition:

Overdrawn organic syndromes which in common have an acquired and total weakening of all the psychic activity, with deterioration of the intellectual, emotional and social functions, being accompanied by a deterioration of the somatic state.

Spontaneously irreversible.

Chronic and progressive evolution.

Etiology:

They are multiple.

To always seek a curable cause.

Semiology:

Disorders of the reasoning.

Disorders of the judgement: incapacity to criticize a history.

Disorders of the attention: incapacity to learn from the new things.

Disorders of the space-time orientation.

Speech difficulties: impoverishment of the language; difficulty of finding its words.

Motor disorders: difficulties of achieving some gestures.

Gnostic disorders: difficulties of recognizing objects or faces.

Disorders of the memory on recent facts.

Behavioral problems: runnings away. Inversion of the nychthemeral rate/rhythm.

Hypochondriaques delirious ideas and of persecution.

Modifications of the character: irritability, angers, conduits of opposition, apathy, acts absurd.

Mark a change in the evolution of the patient.

Epidemiology:

The incidence increases with the age.

It is 1% all confused categories of age.

The prevalence also increases with the age:

• 2 to 3% for the subjects of more than 70 years

• 20% for the subjects of more than 80 years No influence of the sex.

No the cultural influence.

No the influence of the socio-professional medium.

45% live with a spouse 23% with their children 20% live only 12% in institution

Positive diagnosis:

It is especially clinical.

A - PHASE OF BEGINNING:

The person consults for disorders of the memory relating to the recent facts.

Character or behavioral problems.

Psychiatric disorders:

• Depressive State

• Delirious Ideas of persecution

To carry out complementary examinations.

To make specify the family antecedents.

To make pass from the tests.

B - PHASE Of STATE:

• Neglected Presentation

• Inexpressive Mimicry

• Dispersion

• Disorders of the orientation temporo-spaciale

• Disorders of the memory

• Speech difficulties

• Disorders of the reasoning

• Loss of the ethical direction

• Disturbance of self-criticism and the judgement

Signs of accompaniment:

• Disorders of affectivity

• Disinterest marked for all the activities

• Inappropriate emotional Reactions

• Lack of emotional control

• Some are agitated, the other apragmatiques ones

• Désinsertion social being worsening

• Violence

• Indecent assaults

According to the etiology, disturb somatic:

• Extrapyramidaux neurological Disorders

• Disorders of walk

• Total physical Deterioration

Evolution:

Without treatment, towards death in a state of constant mental and physical deterioration.

Complementary examinations:

1) BIOLOGICAL EXAMINATIONS:

• NFS

• VS

• Proportioning folates

• Proportioning B12 vitamin

• Thyroid Assessment

• Blood Ionogramme

• Urea, créat, glycemia

• Serology syphilis

2) NEUROLOGICAL ASSESSMENT:

• Cerebral Scanner

• Fund of eye

• EEG

• Lumbar Puncture

3) CARDIOVASCULAR ASSESSMENT:

• ECG

Radio • pulmonary

• Echo-Doppler of the vessels of the neck

• Proportioning cholesterol and triglycerides

4) PERSONALITY TESTS:

5) TESTS PSYCHO-COMPORTEMENTAUX:

Differential diagnosis:

1) DEPRESSIVE SYNDROME:

• The depressive elements precede the intellectual deficit (the reverse in the demented person)

• One can precisely date the beginning from the disorders (impossible in the demented person)

• Sometimes, one can find a starting factor (not factor starting in the demented person)

• Family Factors

• Sadness

• Psychomotor Deceleration

• Intellectual Performances attacks partially

• Disorders often limited to the disorders of the memory

• No signs of organicity

In the demented person:

• Refusal of the disorders

• No anxiety

• Indifference, apathy

• Signs of organicity

• Globality of the disorders

It is the result of the antidepressant treatment which confirms the diagnosis.

2) CONFUSIONAL SYNDROME:

• Acute, brutal Beginning (insidious in the demented people)

• Disorders of vigilance (can be normal in the demented people)

• Disturbed Perception: visual hallucinations (in the demented people: auditive hallucinations)

• Anxious Perplexity (does not exist in the demented person)

• Variation of symptomatology (not of variations in the demented people)

• Reversible Evolution (chronic and spontaneously irreversible in the demented people)

• Disturbed Orientation and attention (can be preserved in certain insanities)

3) APHASIA:

Limited deficit; whereas it is total for the insanity.

4) DELIRIOUS SYNDROME:

The intellectual functions are not weakened.

Etiology:

A - DEGENERATIVE INSANITIES:

Unknown origin.

Rarefaction of the neurons

Degeneration of the neurons.

Diffuse cortical atrophy.

1) INSANITIES PRESENILES:

has) Disease of Alzheimer

b) Disease of Pick

2) SENILE INSANITIES:

a) Parkinson's disease

b) Chorée de Huntington

Hereditary disease which begins between 30 and 40 years by personality disorders and behavior.

Disorders of memory to the phase of state.

Disorders of the attention.

Neurological anomalies: movements choreic.

Disorders of irregular and unbalanced walk.

Irrational syndrome sometimes accompanied by one mania persecution.

The evolution is done towards death into 15 to 20 years.

c) Disease of Creutzfeld-Jakob

Viral origin.

Abnormal movements.

Hypertonicity extrapyramidale.

Epileptic fits.

Psychiatric demonstrations:

• Disorders of mood

• Delirious Syndrome

Evolution quickly fatal.

B - VASCULAR INSANITIES AND ARTERIOPATHIQUES:

C - CURABLE INSANITIES OF CAUSES:

1) MEDICAL CAUSES:

a) The hypothyroïdie:

Disease of Biermer: deprive of B12 vitamin.

General paralysis.

In fact a tertiary syphilis which appears after 20 years of untreated syphilitic infection.

Delirious ideas.

Megalomania.

Neurological signs.

Hesitant step.

Sign of Argyll-Robertson: myosis irregular.

b) Deprive of folates

c) Deficiency in PP vitamins

2) NEUROSURGICAL CAUSES:

a) Cerebral tumours

Especially frontal: slow and quiet development.

b) Hématome under-dural

c) Hydrocéphalie with normal pressure

In general secondary with after-effects of meningitis.

3) TOXIC CAUSES:

a) Intoxication with the carbon monoxide

b) Intoxication with lithium

D - INSANITIES RELATED TO THE HIV:

Specific insanities of the old subjects:

A - DISEASE Of ALZHEIMER:

Insidious beginning.

Relatively slow evolution.

1) PRIVATE CLINIC:

Disorders of the memory.

Difficulties for the new trainings.

Difficulties for the usual gestures.

Conscience relating of the disorders to the beginning.

At the end of several months of evolution:

• Important mental Deficiency

• Disorders of the memory

• Confusion temporo-spaciale

• Disorders of affectivity with coléreux behaviors

• Psychomotor Agitation

• Disorders of the judgement and the reasoning

• Speech difficulties: jargonaphasy, palilalie, echolalias, until the aphasia

Aphaso-apraxo-agnosic evolution characteristic of the disease of Alzheimer.

Late neurological disorders.

2) COMPLEMENTARY EXAMINATIONS:

a) Electroencephalogram

Nonspecific diffuse deteriorations.

b) Cerebral scanner

Cortico-under-cortical bilateral atrophy with posterior prevalence.

3) EVOLUTION:

Progressive but nonregular aggravation.

Total dependence.

Leading to died into 8 to 10 years.

4) FACTORS OF RISKS:

• Age

• Previous family

• Chromosome 21 (assumption)

B - DISEASE OF PICK:

Declares itself between 40 and 60 years.

Female prevalence.

1) PRIVATE CLINIC:

a) Beginning:

Progressive like all the atrophic insanities.

Reached:

• Memory

• Attention

• Judgement

Characteristic disorders:

• Behavior

• Affectivity

• Puffed out agitation

• Puerile Euphoria

b) Phase of state:

Worsened irrational state.

The patient is not aware of his deficit.

Apragmatism.

Inertia.

Indifference.

Constant speech difficulties.

The language is impoverished more and more, going towards a complete dumbness.

Echolalia: repetition of the sentences.

Palilalie: repetition of the words.

Orality: tendency to carry the objects to the mouth, to smell.

Gloutonnery.

Hypotonic crises involving of the falls but not epilepsy.

Good orientation temporo-spaciale.

Not be delirious.

No epileptic fits.

No extrapyramidaux signs.

2) COMPLEMENTARY EXAMINATIONS:

a) EEG:

Normal.

b) Cerebral scanner:

Massive bilateral cortical atrophy prevailing in the fronto-temporal areas, with respect of the first temporal convolution.

3) EVOLUTION:

Evolve/move over several years.

Dumbness.

Inertia.

Gatism.

Important deterioration of the state general.

C - SENILE INSANITY:

Start after 65 to 70 years.

Table of irrational syndrome isolated without neurological signs. Nothing with the EEG.

One tends more to differentiate it from the disease of Alzheimer.

It would start simply in a later way.

Evolution towards death in a few years.

D - INSANITIES ARTERIOPATHIQUES:

Had with a cerebral ischaemia.

Factors of risks:

• HTA

• Repeated cerebral Accidents

Beginning after 60 years.

Variable beginning according to the localization.

1) PRIVATE CLINIC:

The beginning can be progressive and insidious or brutal.

Disorders of memory. Bradypsychie.

Confusion temporo-spaciale.

Disorders of mood.

Emotional lability.

Phase of state:

• Evolution by successive jolts

• Irrational Syndrome which worsens gradually

Psychic disorders:

• Thymique Disorders

• Delirious Ideas of damage and persecution

Pseudo-bulbar syndrome:

• Disorders of swallowing

• Disorders of walk

• Disorders sphinctériens

• Homonymous Hémianopsie homolatérale (sign the vascular origin)

2) COMPLEMENTARY EXAMINATIONS:

a) Psychometric test:

Deterioration prevailing in the verbal field.

b) EEG:

Frequent and asymmetrical anomalies.

c) Fund of eye:

The hemianopsy is found.

d) Cardiovascular assessment:

Factors of risks:

• Tobacco

• HTA

• Diabetes

• Signs of vascular attacks peripheral: blow carotidien

e) Scanner:

Traces of multiple after-effects of accidents.

Disseminated Hypodensities.

Therapeutic control:

A- SYMPTOMATIC TREATMENT:

a) Anxiety when it exists:

Rather carbamates that benzodiazepines.

Small amounts not to add to confusion.

b) Agitation:

Nerve sedatives with small amounts.

c) Of the associated depression:

Light antidepressants: VIVALON.

B - PALLIATIVE TREATMENT:

To try as well as possible to improve the quality of life of the patients:

• Vasodilators for the disease of Alzheimer

• Anti-ischaemic

• Treatments aiming at improving the memory: TANAKAN

C - MEASUREMENTS Of ASSISTANCE:

In residence allowing to leave the patient in his environment longest possible to avoid worsening confusion.

Specialized houses when the maintenance in residence is not possible any more.

D - PROTECTION MEASURES:

• Safeguard of justice

• Trusteeship

• Supervision To stimulate the patient as much as possible to slow down the progression of the handicap.

To avoid moving the patient of a place to another.

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