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Organic Mental Disorders

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  • Fleeting: fast, fragmentary: small
  • Transcript

    • 1. Delirium Dementia Organic Amnestic Syndrome Other Organic Mental Disorders
    • 2. Organic – due to
      • Primary Brain Pathology
      • Secondary Brain Dysfunction to Systemic Disease
      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. A. 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
    • 4. Clinical Features
      • Acute
      • Clouding of conciousness
      • Disorientation (mostly time, severe cases place and person)
      • Short attention span/distractibility
      • Perceptual Distortion
      • Disturbance in sleep wake cycle
      DECREASE AWARENESS TO SURROUNDING DECREASE ABILITY TO RESPOND TO ENVIRONMENTAL STIMULI ILLUSIONS HALLUCINATIONS Mostly Visual INSOMNIA DAY TIME SLEEPINESS
    • 5.
      • Sun Downing – six in evening
        • New Memory Impairement
        • Relatively intact remote memory
      • Speech
      • Mood – Fear, anger rage
      • Delusions – Fleeting and fragmentary
      • Neuro: Tremors, Dysphasia, Urinary incontinence
      IMPAIRED IMMEDIATE RECALL IMPAIRED RECENT MEMORY SLURRING of SPEECH INCOHERANCE
    • 6. Predisposing Factors
      • Old age
      • Pre existing brain damage/dementia
      • Past history of delirium
      • Alcohol /drug dependence
      • Chronic Medical illness
      • Surgical procedures
      • History of Head Injury
    • 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. Management of Delirium
      • 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
      • Correct underlying cause –
      • If underlying cause is found then it must be treated immediately . For ex
        • 50mg of 50% IV dextrose for HYPOGLYCEMIA
        • 02 for HYPOXIA
        • IV fluids for electrolyte imbalance
    • 9.
      • 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
    • 10. DELIRIUM VS DEMENTIA
    • 11. B. DEMENTIA
    • 12.
      • 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
    • 13. 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
    • 14.
      • 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
    • 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. ALZHEIMER’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
    • 17. MULTI 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)
      TIA HPT CVS DISEASE PREVIOUS STROKE
    • 18. AIDS 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
    • 19. 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
    • 20. C. ORGANIC AMNESTIC SYNDROME
      • Characterized by
        • Memory impairment (anterograde, retrograde amnesia) due to an underlying organic cause.
        • No impairment of global intellectual function,abstract thinking,personality.
      • Caused by Thiamine deficiency in alcohol dependence as part of Wernicke Korsakoff Syndrome
      • Any other lesions involving bilaterally the inner core of limbic system(i.e mammillary bodies,fornix,hippocampus, medial temporal lobe,)
    • 21.
      • The Lesions include:
      • Head trauma
      • Surgical procedure
      • Hypoxia
      • Posterior cerebral artery stroke
      • Herpes simplex encephalitis
    • 22. Management
      • Treat the underlying cause if treatable.Ususally treatment is of not much help,except in prevention of further deterioration and the prognosis is poor
    • 23. D. Other Organic Mental Disorders
      • Organic Hallucinosis
      • Organic Catatonic Disorder
      • Organic Delusional (Schizo like) disorder
      • Organic Personality Disorder
    • 24. Organic Hallucinosis
      • Etiology:
      • Drugs:Hallucinogens,cocaine,cannabis,bromide)
      • Alcohol:In alcoholic hallucinosis,auditory hallucinations are more common
      • Migraine
      • Epilepsy: Complex partial seizures
      • Brain stem lesions
    • 25.
      • Persistant or recurrent hallucinations due to an underlying organic cause.
      • No major disruption of consciousness, intelligence or memory
      • Management
      • 1)Treatment of the underlying cause if treatable.
      • 2) Symptomatic treatment with a low dose of an anti-psychotic drug.
    • 26. Organic Catatonic Disorder
      • Etiology:
      • Neurologic disorders: limbic encephalitis,Surgical procedures,sub dural hematoma,cerebral malaria
      • Systemic and metabolic disorders : Diabetic ketoacidosis , pellagra, SLE, Hepatic encephalopathy
      • Drugs and poisoning: Organic alkoloids ,aspirin,lithium poisoning ,ethyl alcohol , co
      • Psychiatric disorders : manic stupor , periodic catatonia , reactive psychosis ,schizophrenia
    • 27. Management
      • Treatment of underlying cause
      • Symptomatic treatment with low doses of benzodiazipam or an anti-psychotic or electro convulsive therapy.
    • 28. Organic delusional disorder
      • Predominant delusions which are persistant or recurrent ,caused by an underlying organic cause.
      • No major disturbance of consciousness,orientation , memory or mood.
      • Etiology:
      • Drugs:Amphetamines,cannabis,disulfimes
      • Spino cerebellar degeneration
      • Complex partial seizures
    • 29. Management
      • Treatment of underlying cause
      • Symptomatic treatment with low doses of benzodiazipam or an anti-psychotic or electro convulsive therapy.

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