Organic Mental DisordersOrganic Mental Disorders

DeliriumDementia

Organic Amnestic SyndromeOther Organic Mental Disorders

Organic – due to • Primary Brain Pathology• Secondary Brain

Dysfunction to Systemic Disease

Organicity/ High index of suspicion for an organic problem: 1. First Episode 2. Sudden Onset 3. Older Age at onset 4. Hx of Drug/Alcohol abuse 5. Concurrent medical/neurological problem 6. Neurological signs: Seizures, LOC, Head injury, sensory motor deficit. 7. Presence of Confusion/Disorientation 8. Presence of visual and non auditory (olfactory, gustatory, tactile) hallucinations

A. DELIRIUMA. DELIRIUM• Commonest organic mental disorder• Definition: Acute organic brain syndrome

characterized by clouding of consciousness and disorientation develops over a brief period and remits immediately once offending cause is removed.

• Epidemiology: - 5 to 15% of medical & surgical px; - High in post op patients; - 40-50% recovering from hip surgery; - Highest rate in post cardiotomy patients; - 30% in ICU

Clinical Features1. Acute2. Clouding of conciousness3. Disorientation (mostly time,

severe cases place and person)4. Short attention

span/distractibility5. Perceptual Distortion6. Disturbance in sleep wake cycle

DECREASE AWARENESS TO SURROUNDINGDECREASE ABILITY TO RESPOND TO ENVIRONMENTAL STIMULI

ILLUSIONSHALLUCINATIONS Mostly Visual

INSOMNIADAY TIME SLEEPINESS

7. Sun Drowning – sx in evening8. New Memory Impairement Relatively intact remote memory

9. Speech 10.Mood – Fear anger rage11.Delusions – Fleeting and fragmentary12.Neuro: Tremors, Dysphasia, Urinary

incontinence

IMPAIRED IMMEDIATE RECALLIMPAIRED RECENT MEMORY

SLURRING of SPEECHINCOHERANCE

Mini MENTAL STATE EXAMfor COGNITIVE IMPAIREMENT

• Orientation (10), Registration (8), Language (8), Recall (3), Construction (1)

• < 25/30 = probable impairement• < 20/30 = definitive impairement

Predisposing Factors• Old age• Preexisting brain damage/dementia• Past hx of delirium• Alcohol drug dependence• Chronic Medical illness• Surgical procedures• Rx with psychotropic drugs• Hx of Head Injury

Differential Diagnosis

• Dementia• Mania• Schizophrenia• Depression

Organic ETIOLOGY of DeliriumCLASS ETIOLOGY

METABOLIC Hypoxia, Anemia, Electrolyte disturbance, Hepatic&Uremic Encephalopathy, Cardiac failure,arrest,arrythmia, Hypoglycemia, Metabolic acidosis&alkalosis, Shock

ENDOCRINAL Pituitary, Thyroid, Parathyroid, Adrenal dysfunctions

DRUG/SUBSTANCE (Many) including alcohol, benzodiazepines, anticholinergics, psychotropics, lithium, AntiHPT, diuretics, anticonvulsant, digoxin, heavy metals, Insulin, salicylates

NUTRITIONAL DEFICIENCIES

Thiamine, Niacine, Pyridoxine, Folic Acid

INFECTIONS (ACUTE/CHRONIC) Septicemia, Pneumonia, Endocarditis, UTI, Meningitis, Encephalitis, Cellulitis

INTRACRANIAL Stroke, Post Ictal, Head Injury, Infections, Migraine, Focal abscess/neoplasms, Hypertensive Encephelopathy

MISCELLANEOUS Post op, ICU, Sleep deprivation

Management of Delirium

• If cause not known – Do a battery of investigations : FBC, Urinalysis, Blood glucose, BUSE, Liver and renal function test, arterial p02, Pco2, Thyroid function, B12, Folate levels, CXR, ECG, CSF, Drug screen, VDRL, HIV, EEG, CT MRI

• Correct underlying cause – ex– 50mg of 50% IV dextrose for HYPOGLYCEMIA– 02 for HYPOXIA– IV fluids for electrolyte imbalance

• Drugs given if patient is agitated (most are):– Small dose BENZODIAZEPINES

(Lorazepam, Diazepam)– ANTIPSYCHOTIC (Haloperidol)

MAINTAIN WITH ORAL HALOPERIDOL, LORAZEPAM TILL RECOVERY IN 1 WEEK

REVIEW DOSE, TAPER AND STOP

DELIRIUM VS DEMENTIA

B. DEMENTIAB. DEMENTIA

• Definition: Chronic Mental Disorder characterized by impairement of intellectual functions, Impairement of memory and deterioration of personality with the course being progressive, stationary or reversible

CLINICAL FEATURES

• Duration: 6 months• Impaired Intellectual functions• Impairement of memory (initially mild, remote

memory in later stage)• Deterioration of personality with lack of

personal care• No conscious impairment• Orientation-usually normal but falls later

• Aphasia – Difficulty in naming an object• Hallucinations and Delusions

• Additional:-- Emotional lability: Marked variable emotional expression- Catastrophic rxn: When asked to do something beyond her intellectual capibility, she goes into a rage

DIFFERENTIAL DIAGNOSIS

• Normal Aging (usually not sufficient to intefere with social or occupational function)

• Delirium• Depression• Factitious disorder – pseudodementia – complains

about impairement, emphasize disability, communicates distress, Don’t know answers (unlike dementia makes mistakes), confabulation rare

• Schizophrenia

Types and causes Of DementiaTYPE CAUSES

Parenchymatous Brain Disease

Alzheimers Disease, Parkinson’s disease, Huntingtons’s Chorea, Pick’s Disease, Steel-Richardson syndrome (prog. Supranuclr palsy)

Vascular Dementia

Multiinfarct Dementia, Subcortical Vascular dementia (Binswanger’s disease)

Toxic Dementia Alcohol, Drugs, Heavy Metals, Bromide, CO, Benzodiazepines, Psychotropics

Metabolic Dementia

Chronic hepatic/uremic encephalopathy, dialysis dementia, Wilson’s disease

Endocrinal Pituitary, Parathyrois, Thyroid, Adrenal dysfunction

Deficiency Dementia

Pernicious anemia, Pellagra, Folic acid, Thiamine deficiency

Infections AIDS, Neurosyphillis, Chronic Meningitis, Creutzfelft-Jacob disease

IOP ↑ Brain tumor, Headinjury hematoma, hydrocephalus

Commonest: ALZHEIMERS DEMENTIA, MULTIINFARCT DEMENTIA, HYPOTHYROID DEMENTIA, AIDS DEMENTIA COMPLEX

ALZHEIMER’S DEMENTIAALZHEIMER’S DEMENTIA• Women, Genetic• ↓ neurotransmitter AcetylCholine due to

degeneration of cholinergic nuclei in basal forebrain• Drugs: – Rivastigmine (1.5-6mg/day), Galantamine (4-12mg BID) -

> ↑Ach by slowing its degredation– Memantine (5-20mg/day) -> N, Methyl D Aspartate

(NMDA) antagonist– Vitamin E

MULTI INFARCT DEMENTIAMULTI INFARCT DEMENTIA

• Multiple cerebral infarcts causing dementia due to underlying CVS problem

• Abrupt onset, Acute exacerbations, Step wise clinical deterioration, Fluctuating course

• Focal Neurological signs• Investigations: EEG (focal area of

slowing) CT brain (multiple infarct area)• Treatment: Underlying (eg HPT)

TIAHPTCVS DISEASEPREVIOUS STROKE

AIDS DEMENTIA COMPLEXAIDS DEMENTIA COMPLEX

• 50-70% patient of AIDS• Triad of cognigtive, behavioral, motoric

deficits, -> subcortical dementia• Virus cross BBB -> Cognitive impairement• Ix ELISA, Western Blot• CT may show cortical atrophy

MANAGEMENT OF DEMENTIA

• Basic investigations• Treat underlying cause – mentioned• Symptomatic management of anxiety,

depression, Psychotic symptoms• Education – Family, Financial, Support groups• Institutionalize in later stage

C. ORGANIC AMNESTIC SYNDROMEC. ORGANIC AMNESTIC SYNDROME

• Characterized by– Memory impairment (anterograde, retrograde

amnesia)– No impairment in immediate retention and recall,

attention, consciousness, global intellect • Caused by Thiamine deficiency in alcohol

dependence as part of Wernicke Korsakoff Syndrome

• Rx: High dose Thiamine

D. Other Organic Mental DisordersD. Other Organic Mental Disorders

• Organic Hallucinosis• Organic Catatonic Disorder• Organic Delusional (Schizo like) disorder• Organic Mood (Affective) disorder• Organic Anxiety disorder• Organic Personality Disorder

THANK UTHANK U• “I have recently been told that I am one of the

millions of Americans who will be afflicted with Alzheimer's Disease... At the moment I feel just fine. I intend to live the remainder of the years God gives me on this earth doing the things I have always done... I now begin the journey that will lead me into the sunset of my life. I know that for America there will always be a bright dawn ahead. Thank you, my friends. May God always bless you”– President Ronald Reagen (1911 –2004)