2. What Is Organic Brain
Syndrome?
It is also known as:
Acute confusional state (ACS)
Minimal brain dysfunction (MBS)
ICU psychosis (ICUP)
Acute brain failure (ABF)
Encephalopathy
Organic VS functional illness
3. Definitions
“Organic” versus “functional”
Example: organic psychosis versus functional
psychosis
Organic = demonstrable structural diseases
Analogous to hardware versus software failure
Syndrome versus disorder
Example: organic brain syndrome versus
organic mental disorder
Syndrome = signs and symptoms + qualifiers
Disorder = syndrome + etiology
4. Generalized
Acute onset and
usually reversible
Delirium
(acute generalized psychological impairment)
Gradual onset and
usually irreversible
Dementia
(chronic generalized psychological impairment)
Focal
Specificimpairment
Memory Amnesic disorder
(specific memory impairment)
Perception Organic hallucinosis
Thinking Organic anxiety disorder
Mood Organic mood disorder
Syndrome Organic personality disorder
Dysfunction Of The Brain
5. Dementia Amnesic
disorders
Delirium
Cognitive Disorders
Due to General Medical condition
Substance-induced
Substance-withdrawal
Due to multiple etiologies
Alzheimer’s disease
Vascular dementia
DDT HIV disease
DDT head trauma
DDT Parkinson’s disease
DDT Pick’s disease
DDT Creutzfeldt-Jacob disease
6. Organic Mental Disorders
Other Mental Disorders
Due to brain damage and dysfunction
and to physical disease
Personality and Behavioral Disorders
Due to brain disease, damage and dysfunction
Organic hallucinosis
Organic delusional disorder
Organic mood disorder
Organic anxiety disorder
Organic personality disorder
Postencephalitic syndrome
Postconcussional syndrome
7. Organic Brain Syndrome Organic Mental Disorder
Delirium
Substance-induced delirium
Delirium DTGMC
Dementia
Alzheimer’s disease
Vascular dementia
Amnesic disorder Amnesic disorder DTGMC
DTGMC – due to a general medical condition
9. DSM-IV Criteria for Delirium
A. Disturbance of consciousness and
distractibility
B. Cognitive change (memory deficit,
disorientation, language disturbance) or
perceptual disturbance
C. Rapid onset
D. Due to general medical condition
10. Key Points
Delirium generally involves…
Acute onset of symptoms
Fluctuation of symptoms
A precipitating medical cause
Reversible
12. Clinical Presentation …
Cognitive functioning
Perception
• Distortions, illusions, hallucinations
• Frequently attributed to dreaming and manifest
initially at night
Thinking
• Disorganized, fragmented speech patterns,
distracted
Memory
• Registry, retrieval & retention impaired
• Partially/completely amnestic of the delirious period
13. … Clinical Presentation
Orientation
• Impaired to immediate orientation, recent
events, time of day, etc.; Global orientation
intact (person, place, and thing)
• Usually to time and place, rarely to person
• Frequently overlooked (e.g., Hospital
psychosis)
Attention
• Inattentive or hypervigilant
• Appear to “drift off” in thought
14. … Clinical Presentation
Wakefulness
*Disruption of sleep-wake cycle
• Sleep during the day, awake at night
• “Sundowning” we go home, they get up
• If not agitated, can mimic depression or anxiety
Psychomotor behavior
Hyperactive vs. Hypoactive vs. Mixed
• Fluctuations
• Can lead to injury
15. … Clinical Presentation
Emotion
Varies from patient to patient in
severity, lability and duration
• Anger
• Agitation
• Anxiety
• Depression
Family and friends typically first to
notice
17. Risk Factors for Delirium
Elderly
Children
Previous organicity
Drug or alcohol abuse
Postcardiotomy
Severe Burns
Infirmities of senses
18. Work-Up of Delirium
History, physical and neurological exam
Drug(prescribed, OTC and illicit) and
alcohol history and screening
CBC with differential electrolytes, TFT’s,
B12, Folate, VDRI, ESR, U/A, LFT’s,
Ammonia level
Chest x-ray, EKG, EEG, and ABG’s
Psychiatric evaluation
19. Etiology of Delirium
Dopaminergic - cholinergic balance:
Ach - cognitive disturbances
↑ DA - agitation, hallucinations,
delusions
20. Management Of Delirium
Find the cause(s)
Usually multifactorial
Look for medication toxicity
Re-orient patient
Glasses/hearing aids
Quiet, unstimulating environment
Attention to patient concerns & fears
Reassurance of family re: transient nature
Antipsychotic medications for agitation
Benzodiazepines often makes delirium worse
1:1 observation/restraints only when needed
21. Dementia
Forgetfulnes
s
… is a generalized impairment of intellect, memory and
personality, with no impairment of consciousness
22. DMS-IV Criteria for Dementia
A. Memory impairment
B. At least one of the following:
1. Language problems (aphasia)
2. Motor problems (apraxia)
3. Agnosia
4. Disturbed executive functioning
23. Characteristic Features
Cognitive Symptoms Psychological Impairment
*Amnesia (forgetfulness) Memory (ST > LT)
± Aphasia Language
± Apraxia Motor tasks
± Agnosia Object recognition
± Executive dysfunction
Planning, organizing,
sequencing and abstracting
24. Clues to Abnormal Memory
Changes
Learning and retaining new information
repetitive questions
frequent phone calls
misplacing objects
missed appointments
Increasing difficulty with:
25. Clues to Abnormal Memory
Changes
Learning and retaining new information
Handling complex tasks
balancing check book
completing book
following menu
Increasing difficulty with:
26. Clues to Abnormal Memory
Changes
Learning and retaining new information
Handling complex tasks.
Reasoning ability
disregard for normal social rules
marked anxiety with unexpected
failing unexpectedly
Increasing difficulty with:
27. Clues to Abnormal Memory
Changes
Learning and retaining new information.
Handling complex tasks.
Reasoning ability.
Spatial ability and orientation
driving accidents
getting lost
accidents in the home
Increasing difficulty with:
28. Clues to Abnormal Memory
Changes
Learning and retaining new information.
Handling complex tasks.
Reasoning ability.
Spatial ability and orientation.
Language
word hunting
grammatical errors
simplified language
Increasing difficulty with:
29. Clues to Abnormal Memory
Changes
Learning and retaining new information.
Handling complex tasks.
Reasoning ability.
Spatial ability and orientation.
Language.
Behaviour
more passive
misinterprets stimuli
change in appearance
cleanliness
Increasing difficulty with:
30. Staging of Dementia
Progressive dementias are staged according to
the level of functional impairment
Mild impairment: difficulties balancing a checkbook
Moderate impairment: difficulties in household
cleanup, requires some assistance in self-care
Severe impairment: requires considerable assistance
in feeding, grooming, toileting
Profound impairment: patient oblivious to
surroundings
(Reisberg ‘82, Hughes ‘82)
32. Key Points
Generally a long term and insidious
onset with hallmark events
Underlying medical condition
Rarely reversible
33. ALGORITHM FOR THE DIAGNOSIS OF DEMENTIA
Complaints of memory loss
Suspect
dementia
Subjective
complaints
Caregiver confirms
Decline in function
Objective evidence of cognitive decline
Symptoms may be the
result of depression or
anxiety. Re-evaluation in
3-6 months.
Take history of illness from patient and reliable
information, including:
Onset of symptoms; duration of symptoms;evolution of
symptoms; precipitating factors; family history
Conduct physical examinations
Conduct mental & functional assessment
( e.g.. MMSE & FAQ)
Conduct laboratory tests
(CBC, TSH, electrolytes, calcium glucose)
Conduct other tests as indicated
(CT or MRI in specific cases)
Eliminate presence of reversible conditions:
- substance abuse; adverse drug effects;
depression; metabolic disorders; systemic illness. Treat these causes
Diagnosis of dementia confirmed
Are there other causes
for the symptoms?
YES NO
YES
YES
NO
NO
YES
NO
35. Dementia
* Insidious onset with unknown date
* Slow, gradual, progressive decline
* Generally irreversible
* Disorientation late in illness
* Slight day-to-day variation
* Less prominent physiological
changes
* Consciousness clouded
only in late stage
* Normal attention span
* Disturbed sleepwake cycle;
daynight
* Psychomotor changes late in illness
Delirium
* Abrupt, precise onset, known date
* Acute illness, lasting days or
weeks
* Usually reversible
* Disorientation early in illness
* Variable, hour by hour
* Prominent physiological changes
* Fluctuating levels of consciousness
* Short attention span
* Disturbed sleepwake cycle;
hour-to-hour variation
* Marked early psychomotor
changes
Ham,
36. Dementia
* Insidious onset
* No psychiatric history
* Conceals disability
* Near-miss answers
* Mood fluctuation day to day
* Stable cognitive loss
* Tries hard to perform but is
unconcerned by losses
* Short-term memory loss
* Memory loss occurs first
* Associated with a decline in
social function
Depression
* Abrupt onset
* History of depression
* Highlights disabilities
* ’Don't know' answers
* Diurnal variation in mood
* Fluctuating cognitive loss
* Tries less hard to perform
and gets distressed by losses
* Short- and long-term memory loss
* Depressed mood coincides with
memory loss
* Associated with anxiety
Dementia or depression
Ham, 1997, modified from Wells CE,
38. 10% = “apparent dementia”
D drugs
E emotional illness
M metabolic & endocrine disorders
E eye and ear problems
N nutritional
T tumour or trauma
I infection
A alcoholism
Reversible Causes of Dementia
40. Alzheimer’s Disease C B N
Vascular Dementia C + N + B
Dementia of Lewy Body N + C B
Frontotemporal Dementia B C N
Parkinson’s Disease N C B
Normal Pressure Hydrocephalus N C B
Type of Dementia Typical Presentation
C – cognitive, N – neurological, B - behavioral
47. Dementia Due to
Parkinson’s Disease
Parkinson’s disease is accompanied by
dementia in 20-60% of cases
Dementia has insidious onset and slow
progression and occurs late in course
Characterized by cognitive and motoric
slowing, executive dysfunction, and
impairment in memory retrieval
48. Dementia Due to Lewy
Body Disease
Lewy body disease is similar to Alzheimer’s disease
but has earlier and more prominent visual
hallucinations and Parkinsonian features and more
rapid evolution
Marked by presence of Lewy inclusion bodies in
cerebral cortex
Lewy Body disease accounts for 7-26% of dementia
cases.
(McKeith ‘94)
49. Dementia Due to Pick’s
Disease
Pick’s disease is characterized by changes in
personality, executive dysfunction, deterioration of
social skills, emotional blunting, behavior
disinhibition, and prominent language abnormalities
Features of dementia follow later in course and may
be accompanied by apathy or agitation
55. Reasons For Wandering
Changed environment
Loss of memory
Excess energy
Searching for the past
Expressing boredom
Confusing night with day
Continuing a habit
Agitation
Discomfort or pain
A job to perform
Dreams
56. What is Sundowning?
People with dementia may become more
confused, restless and insecure late in the
afternoon or early evening
They may become more demanding, restless,
upset, suspicious disoriented and even see,
hear or believe things that aren’t real,
especially at night
57. What Causes Sundowning?
Lack of sensory stimulation after dark
Attempt to restore sense of familiarity or security
Anxious about “going home” or “finding mother”
security and protection
Restlessness due to hunger, discomfort, pain
or needing to use a toilet
58. What to do?
Keep the person active in the morning and encourage
a rest after lunch
Don’t physically restrain the person
Let them pace where they are safe. A walk outdoors can help reduce
restlessness
Consider the effect of bright lights and noise from
television and radios
Are these adding to the confusion and restlessness?
Nightlights or a radio playing softly may help the
person sleep
59. Non-Pharmacological Strategies
for Treating the Violent Patient
Enlist the help of family when indicated
Show of force
Behavioral limits in a calm reassuring voice
Offer sedation
Physical restraints
