Organic Mental Disorders


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  • Fleeting: fast, fragmentary: small
  • Organic Mental Disorders

    1. 1. Delirium Dementia Organic Amnestic Syndrome Other Organic Mental Disorders
    2. 2. Organic – due to <ul><li>Primary Brain Pathology </li></ul><ul><li>Secondary Brain Dysfunction to Systemic Disease </li></ul>Suspicion of organic mental disorder : 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
    3. 3. A. DELIRIUM <ul><li>Commonest organic mental disorder </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>
    4. 4. Clinical Features <ul><li>Acute </li></ul><ul><li>Clouding of conciousness </li></ul><ul><li>Disorientation (mostly time, severe cases place and person) </li></ul><ul><li>Short attention span/distractibility </li></ul><ul><li>Perceptual Distortion </li></ul><ul><li>Disturbance in sleep wake cycle </li></ul>DECREASE AWARENESS TO SURROUNDING DECREASE ABILITY TO RESPOND TO ENVIRONMENTAL STIMULI ILLUSIONS HALLUCINATIONS Mostly Visual INSOMNIA DAY TIME SLEEPINESS
    5. 5. <ul><li>Sun Downing – six in evening </li></ul><ul><ul><li>New Memory Impairement </li></ul></ul><ul><ul><li>Relatively intact remote memory </li></ul></ul><ul><li>Speech </li></ul><ul><li>Mood – Fear, anger rage </li></ul><ul><li>Delusions – Fleeting and fragmentary </li></ul><ul><li>Neuro: Tremors, Dysphasia, Urinary incontinence </li></ul>IMPAIRED IMMEDIATE RECALL IMPAIRED RECENT MEMORY SLURRING of SPEECH INCOHERANCE
    6. 6. Predisposing Factors <ul><li>Old age </li></ul><ul><li>Pre existing brain damage/dementia </li></ul><ul><li>Past history of delirium </li></ul><ul><li>Alcohol /drug dependence </li></ul><ul><li>Chronic Medical illness </li></ul><ul><li>Surgical procedures </li></ul><ul><li>History of Head Injury </li></ul>
    7. 7. Organic ETIOLOGY of Delirium CLASS 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
    8. 8. Management of Delirium <ul><li>If cause not known – Do a battery of investigations : CBC, Urinalysis, Blood glucose, Blood urea serum analysis, Liver and renal function test, arterial p02, Pco2, Thyroid function, B12, Folate levels, CSF, ECG, Drug screen,HIV, EEG, CT & MRI </li></ul><ul><li>Correct underlying cause – </li></ul><ul><li>If underlying cause is found then it must be treated immediately . For ex </li></ul><ul><ul><li>50mg of 50% IV dextrose for HYPOGLYCEMIA </li></ul></ul><ul><ul><li>02 for HYPOXIA </li></ul></ul><ul><ul><li>IV fluids for electrolyte imbalance </li></ul></ul>
    9. 9. <ul><li>Drugs given if patient is agitated (most are): </li></ul><ul><ul><li>Small dose BENZODIAZEPINES (Lorazepam, Diazepam) </li></ul></ul><ul><ul><li>ANTIPSYCHOTIC (Haloperidol) </li></ul></ul>MAINTAIN WITH ORAL HALOPERIDOL, LORAZEPAM TILL RECOVERY IN 1 WEEK REVIEW DOSE, TAPER AND STOP
    11. 11. B. DEMENTIA
    12. 12. <ul><li>Definition : Chronic Mental Disorder characterized by impairment of intellectual functions, Impairment of memory and deterioration of personality with the course being progressive, stationary or reversible </li></ul>
    13. 13. CLINICAL FEATURES <ul><li>Duration: 6 months </li></ul><ul><li>Impaired Intellectual functions </li></ul><ul><li>Impairement of memory (initially mild, remote memory in later stage) </li></ul><ul><li>Deterioration of personality with lack of personal care </li></ul><ul><li>No conscious impairment </li></ul><ul><li>Orientation-usually normal but falls later </li></ul>
    14. 14. <ul><li>Aphasia – Difficulty in naming an object </li></ul><ul><li>Hallucinations and Delusions </li></ul><ul><li>Additional:- </li></ul><ul><li>- Emotional lability: Marked variable emotional expression </li></ul><ul><li>- Catastrophic rxn: When asked to do something beyond her intellectual capibility, she goes into a rage </li></ul>
    15. 15. Types and causes Of Dementia Commonest: ALZHEIMERS DEMENTIA, MULTIINFARCT DEMENTIA, HYPOTHYROID DEMENTIA, AIDS DEMENTIA COMPLEX TYPE 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
    16. 16. ALZHEIMER’S DEMENTIA <ul><li>Women, Genetic </li></ul><ul><li>↓ neurotransmitter AcetylCholine due to degeneration of cholinergic nuclei in basal forebrain </li></ul><ul><li>Drugs : </li></ul><ul><ul><li>Rivastigmine (1.5-6mg/day), Galantamine (4-12mg BID) -> ↑Ach by slowing its degredation </li></ul></ul><ul><ul><li>Memantine (5-20mg/day) -> N, Methyl D Aspartate (NMDA) antagonist </li></ul></ul><ul><ul><li>Vitamin E </li></ul></ul>
    17. 17. MULTI INFARCT DEMENTIA <ul><li>Multiple cerebral infarcts causing dementia due to underlying CVS problem </li></ul><ul><li>Abrupt onset, Acute exacerbations, Step wise clinical deterioration, Fluctuating course </li></ul><ul><li>Focal Neurological signs </li></ul><ul><li>Investigations: EEG (focal area of slowing) CT brain (multiple infarct area) </li></ul><ul><li>Treatment: Underlying (eg HPT) </li></ul>TIA HPT CVS DISEASE PREVIOUS STROKE
    18. 18. AIDS DEMENTIA COMPLEX <ul><li>50-70% patient of AIDS </li></ul><ul><li>Triad of cognigtive, behavioral, motoric deficits, -> subcortical dementia </li></ul><ul><li>Virus cross BBB -> Cognitive impairement </li></ul><ul><li>Ix ELISA, Western Blot </li></ul><ul><li>CT may show cortical atrophy </li></ul>
    19. 19. MANAGEMENT OF DEMENTIA <ul><li>Basic investigations </li></ul><ul><li>Treat underlying cause – mentioned </li></ul><ul><li>Symptomatic management of anxiety, depression, Psychotic symptoms </li></ul><ul><li>Education – Family, Financial, Support groups </li></ul><ul><li>Institutionalize in later stage </li></ul>
    20. 20. C. ORGANIC AMNESTIC SYNDROME <ul><li>Characterized by </li></ul><ul><ul><li>Memory impairment (anterograde, retrograde amnesia) due to an underlying organic cause. </li></ul></ul><ul><ul><li>No impairment of global intellectual function,abstract thinking,personality. </li></ul></ul><ul><li>Caused by Thiamine deficiency in alcohol dependence as part of Wernicke Korsakoff Syndrome </li></ul><ul><li>Any other lesions involving bilaterally the inner core of limbic system(i.e mammillary bodies,fornix,hippocampus, medial temporal lobe,) </li></ul>
    21. 21. <ul><li>The Lesions include: </li></ul><ul><li>Head trauma </li></ul><ul><li>Surgical procedure </li></ul><ul><li>Hypoxia </li></ul><ul><li>Posterior cerebral artery stroke </li></ul><ul><li>Herpes simplex encephalitis </li></ul>
    22. 22. Management <ul><li>Treat the underlying cause if treatable.Ususally treatment is of not much help,except in prevention of further deterioration and the prognosis is poor </li></ul>
    23. 23. D. Other Organic Mental Disorders <ul><li>Organic Hallucinosis </li></ul><ul><li>Organic Catatonic Disorder </li></ul><ul><li>Organic Delusional (Schizo like) disorder </li></ul><ul><li>Organic Personality Disorder </li></ul>
    24. 24. Organic Hallucinosis <ul><li>Etiology: </li></ul><ul><li>Drugs:Hallucinogens,cocaine,cannabis,bromide) </li></ul><ul><li>Alcohol:In alcoholic hallucinosis,auditory hallucinations are more common </li></ul><ul><li>Migraine </li></ul><ul><li>Epilepsy: Complex partial seizures </li></ul><ul><li>Brain stem lesions </li></ul>
    25. 25. <ul><li>Persistant or recurrent hallucinations due to an underlying organic cause. </li></ul><ul><li>No major disruption of consciousness, intelligence or memory </li></ul><ul><li>Management </li></ul><ul><li>1)Treatment of the underlying cause if treatable. </li></ul><ul><li>2) Symptomatic treatment with a low dose of an anti-psychotic drug. </li></ul>
    26. 26. Organic Catatonic Disorder <ul><li>Etiology: </li></ul><ul><li>Neurologic disorders: limbic encephalitis,Surgical procedures,sub dural hematoma,cerebral malaria </li></ul><ul><li>Systemic and metabolic disorders : Diabetic ketoacidosis , pellagra, SLE, Hepatic encephalopathy </li></ul><ul><li>Drugs and poisoning: Organic alkoloids ,aspirin,lithium poisoning ,ethyl alcohol , co </li></ul><ul><li>Psychiatric disorders : manic stupor , periodic catatonia , reactive psychosis ,schizophrenia </li></ul>
    27. 27. Management <ul><li>Treatment of underlying cause </li></ul><ul><li>Symptomatic treatment with low doses of benzodiazipam or an anti-psychotic or electro convulsive therapy. </li></ul>
    28. 28. Organic delusional disorder <ul><li>Predominant delusions which are persistant or recurrent ,caused by an underlying organic cause. </li></ul><ul><li>No major disturbance of consciousness,orientation , memory or mood. </li></ul><ul><li>Etiology: </li></ul><ul><li>Drugs:Amphetamines,cannabis,disulfimes </li></ul><ul><li>Spino cerebellar degeneration </li></ul><ul><li>Complex partial seizures </li></ul>
    29. 29. Management <ul><li>Treatment of underlying cause </li></ul><ul><li>Symptomatic treatment with low doses of benzodiazipam or an anti-psychotic or electro convulsive therapy. </li></ul>