ORGANIC MENTAL DISORDERS

1. MRS. J.JULIET SUJATHA,M.Sc(N)
MENTAL HEALTH NURSING
PROFESSOR
GANGA COLLEGE OF NURSING
COIMBATORE
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2. ORGANIC
MENTAL
DISORDERS

3. DEFINITION
• An organic mental disorder
is a dysfunction of the brain
that may be permanent or
temporary.

4. CLASSIFICATION
• Delirium
• Dementia
• Organic Amnestic Syndrome
• Other Organic Mental
Disorders

5. CAUSES
 inherited physiology,
 injury, or disease affecting brain
tissues,
 chemical or hormonal abnormalities,
 exposure to toxic materials,
 neurological impairment, or
 abnormal changes associated with
aging

6. DELIRIUM
• 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.

7. 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
• AIDS 30-40%
• General population 1%

8. 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

9. • Sun Drowning – sx in evening
• Memory Impairment --Relatively intact
remote memory, impaired immediate recall,
impaired recent memory
• Speech- (slurring of speech & incoherance)
• Mood – Fear, anger, rage
• Delusions – Fleeting and fragmentary
• Neuro: Tremors, Dysphasia, Urinary
incontinence

10. DIAGNOSIS
• Mini MENTAL STATE EXAM for
COGNITIVE IMPAIREMENT
Orientation (10),
Registration (8),
Language (8),
Recall (3),
Construction (1)
• < 25/30 = probable impairement
• < 20/30 = definitive impairement

11. PREDISPOSING FACTORS
• Old age
• Preexisting brain damage/dementia
• Past history of delirium
• Alcohol drug dependence
• Chronic Medical illness
• Surgical procedures
• Treatment with psychotropic drugs
• History of Head Injury

12. ORGANIC ETIOLOGY OF DELIRIUM
• METABOLIC
Hypoxia,
Anemia,
Electrolyte disturbance,
Hepatic&Uremic
Encephalopathy,
Cardiac failure,arrest,arrythmia,
Hypoglycemia,
Metabolic acidosis&alkalosis,
Shock

13. • DRUG/SUBSTANCE (Many) including
alcohol,
benzodiazepines,
anticholinergics,
psychotropics,
lithium,
Anti HPT, diuretics, anticonvulsant, digoxin,
heavy metals, Insulin, salicylates

14. • NUTRITIONAL DEFICIENCIES Thiamine,
Niacine, Pyridoxine, Folic Acid
• INFECTIONS (ACUTE/CHRONIC)
Septicemia, Pneumonia, Endocarditis, UTI,
Meningitis, Encephalitis, Cellulitis
• ENDOCRINAL
Pituitary, Thyroid, Parathyroid, Adrenal
dysfunctions

15. • INTRACRANIAL
Stroke, Post Ictal, Head Injury,
Infections, Migraine, Focal
abscess/neoplasms, Hypertensive
Encephelopathy
• MISCELLANEOUS
Post op,
ICU,
Sleep deprivation

16. MANAGEMENT OF DELIRIUM
• If cause not known –
FBC,
Urinalysis,
Blood glucose,
BUSE,
Liver and renal function test,
arterial p02, Pco2,
Thyroid function,
B12, Folate levels,

17. • ECG,
• CSF,
• Drug screen,
• VDRL,
• HIV,
• EEG,
• CT
• MRI

18. • Correct underlying cause –
50mg of 50% IV dextrose for
HYPOGLYCEMIA
0xygen for HYPOXIA
IV fluids for electrolyte imbalance

19. • 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

21. B. DEMENTIA
• Chronic Mental Disorder characterized by
impairement of intellectual functions ,
Impairement of memory and deterioration of
personality with the course being progressive,
stationary or reversible
• Dementia is a syndrome usually of chronic and
progressive nature characterized by decline of
memory and intellect

23. THE DEGREES OF DEMENTIA
• Mild
• Moderate
• Serious
• Dementia is usually (80%) an irreversible
process

24. ONSET
• DAT with Early Onset Dementia before the
age of 65 Relatively rapid deterioration
Aphasia, agraphia, alexia, apraxia
• DAT with Late Onset Dementia after the
age 65 Family history of DAT or Down’s
syndrome Slow progression, no insight
Severe impairment of memory,
confabulations

25. 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

26. • Aphasia – Difficulty in naming an
object
• Hallucinations and Delusions
• Additional:- -
• Emotional lability: Marked variable
emotional expression
• Catastrophic Reaction: When asked to
do something beyond her intellectual
capability, she goes into a rage

29. ALZHEIMERS DEMENTIA
• Alzheimer’s disease is a neurological brain disorder.
• Alzheimer’s disease is the most common form of
dementia, a group of disorders that impairs mental
functioning.
• Alzheimer’s is progressive and irreversible.
• Memory loss is one of the earliest symptoms, along
with a gradual decline of other intellectual and
thinking abilities, called cognitive functions, and
changes in personality or behavior.

34. AETIOLOGY

35. AETIOLOGY

36. Stages of Alzheimer’s
• Stage 1: Normal
Mentally healthy person
• Stage 2: Normal aged forgetfulness
Persons over the age of 65 experience subjective complaints of
cognitive and/or functional difficulties
• Stage 3: Mild cognitive impairment
The capacity to perform executive functions also becomes
compromised. Commonly, for persons who are still working, job
performance may decline.
• Stage 4: Mild Alzheimer’s disease
The most common functioning deficit in these patients is a
decreased ability to manage instrumental (complex) activities of
daily life.(ability to manage finances and to prepare meals for

37. Stage 5: Moderate Alzheimer’s disease
This is manifest in a decrement in the ability to
choose proper clothing to wear for the weather
conditions and/or for the daily circumstances
(occasions).
Stage 6: Moderately severe Alzheimer’s disease
At this stage, the ability to perform basic
activities of daily life becomes compromised.
Stage 7: Severe Alzheimer’s disease
At this stage, AD patients require continuous
assistance with basic activities of daily life for survival.

39. CLINICAL FEATURES

40. INVESTIGATION

50. Causes
• Women,
• Genetic
• ↓ neurotransmitter AcetylCholine
due to degeneration of cholinergic
nuclei in basal forebrain

52. • Dementia in Alzheimer’s Disease
• DAT = dementia of Alzheimer's type :
• the most frequent type of dementia
• primary degenerative cerebral disease
of unknown etiology
• characterized with marked reduction of
neurons,
• appearance of neurofibrillary tangles
and senile plaques (beta-amyloid)
especially cholinergic system is affected

53. • DAT with Early Onset
• Dementia before the age of 65
• Relatively rapid deterioration
• Aphasia, agraphia, alexia, apraxia
• DAT with Late Onset Dementia
• after the age 65
• Family history of DAT or Down’s syndrome
• Slow progression,
• no insight
• Severe impairment of memory, confabulations

54. TREATMENT OF DAT
• Cholinesterase inhibitors - ACHEI, BuCHEI
(fysostigmin, rivastigmin, donepezil, rivastigmin,
metrifonat, galantamin, huperzin, tacrin, velnakrin)
• CHEI + selegilin CHEI + lecitin CHEI +
propentophylin (CHEI) + nootropic agents + agents
with a scavanger effect (piracetam, pyritinol,
• Gingko biloba extr.,
• Vitamin E)

55. • Agonists of muscarinic (M 1 , M 3 ) and
nicotinic acetylcholine receptors (nicotine)
• Nootropic agents (cerebral metabolic
enhancers) + Ca channel antagonists
(nimodipin, cinnarizin)
• Nootropic agents + antiinflammatory agents
(acetylosalicylic acid, ibuprofen,
indometacine)
• Nerve growth factors (cerebrolysin)
• Somatostatin deficit (octostatin)

56. Treatment of DAT
• Depression, anxiety - SSRI (citalopram,
fluvoxamin, paroxetin, …), SNRI
(venlafaxin)
• Psychotic + confusional states -
neuroleptics with minimal adrenolytic +
anticholinergic effects (tiaprid, sulpirid,
risperidon, haloperidol, clozapin)

57. • Insomnia - non-benzodiazepine
hypnotics (zolpidem, zopiclon)
Epileptic seizures - carbamazepin,
valproic acid, Na valproate
• C) Psychotherapy
• Reeducation of cognitive,
• emotional + behavioural disorders
• Family therapy
• Alzheimer’s society

58. Alzheimer’s Diagnostic Tests
An interview or questionnaire to identify past medical problems.
Includes evaluations of hearing and sight, heart and lungs, as
well as temperature, blood pressure and pulse readings.
• Neuropsychological testing
Doctors use a variety of tools to assess memory, problem-solving,
attention, vision-motor coordination and abstract thinking, such
as performing simple calculations in your head.
MRI and CT scans look at the structure of the brain and are used
to rule out brain tumors or blood clots in the brain as the reason
for symptoms.

59. Nursing management
• DAILY ROUTINE
1. Drawing up a fixed timetable for waking, toilet,exercise
and meals
2.Bcoz of “sun downing” additional care must be taken in
evening and at night
3.Orient the patient to reality
4.Clock with large faces aid in orientation to time
5.Use calendar with large writing and separate page
6.Provide newspaper which stimulate interest in current
events
7.Give frequent orientation of place, person and time
before approaching.

60. 2.NUTRITION AND BODY WEIGHT
1. Provide well balanced diet( protien,fiber rich and adequate
calories
2. Allow plenty of time for meals
3.Tell patient which meal it is and what is there to eat
4.Food should not be too hot or too cold
5.Patient have sugar craving
6.Take care the patient do not gain weight
7.Consider diet modification for certain illness such as DM,HT
etc
8.Semi-solid diet is safe to prevent aspiration into the lungs

61. 3.PERSONAL HYGIENE
1. Care about patient personal hygiene
2. Kee the skin clean and dry
3. Caustic substances such as spirit or antiseptic should
not be used on the skin
4. Check finger and toe regularly and cut them.
5. Patient have problem with lock on bathroom door
It is advisable to remove the lock
6. Compliment the patient when he/she looks good

62. 4.TOILET HABITS AND INCONTINENCE
1. Maintain rigid routine
2. Conditioned behaviour such as going for bowel
movement after a cup of tea
3.Urinate at fixed interval (season,amount and fliud intake)
4.Check for prostrate problem frequently
5. If incontinence is present identify the underlying cause
6. Constipation is a frequent cause for discomfort
7. It can be avoided by adding fiber supplements and
roughage to diet on daily basis

63. 5.ACCIDENTS
1.Avoid accidents caused by tripping furniture, failing
down the stairs or slipping in the bathroom
2.Avoid loose and poorly fitting footwear and wrinkled
carperts
3. Make to wear soft slip on shoes with straps which fir
securely
4.Make sure lights are bright enough
5.Keep bleach,matches and paints out of reach
6.Dont allow the patient to take medication alone

64. 6.FLUID MANAGEMENT
1. Give sufficient fluid during the day and minimize the fluid
after 6 pm
2. The last cup of tea should be given around 5 pm.
3. Minimize caffeine containing beverages
4. Reduce bed wetting and to reduce the no.of times set up
during the night
7.MOOD AND EMOTIONS
1. Patients have abrupt changes in their moods and emotions
2. Keep a calm environment with fixed daily routine
3. Don’t ask repeated question about choices
4. Mood changes can cause distraction

65. 8. WANDERING
1.Often lose their geographic orientation and can get lost
even in familiar surroundings
2. It is advisable to have identification bracelet or card
3. Doors of the house should be securely locked so they
cant leave unnoticed
4. Accompany the patient while going for walk or outside
the house.
9.DISTURBED SLEEP
1.Sleep pattern disturbances are distressing for the patient
and family
2.Maintain sleep pattern.
3.Napping during day should be avoided.

66. 10.INTERPERSONAL RELATIONSHIP
1. Verbal communication should be clear and unhurried
2. Questions that require yes or no answers are best.
3. Reinforce socially acceptable skills
4. Give necessary information repeatedly
5. Try to make sure that each day something interest
(listening to music, talk about the day’s activities)
6.Try to involve himwith old friends for a chat, reminiscing
about the past

67. 11.IMPAIRED VISUOSPATIAL FUNCTIONING
1. Maintain a familiar environment
2. Give only one task at a time
3. Give non verbal cue along with verbal instruction
4. Speak and move slowly and quietly
5. Address the person by name and introduce oneself
6. Give short explanation before taking any action.
12.CATASTROPHIC REACTION
1. Avoid circumstances that trigger the reaction
2. Keep everyday routine consistent and simple.
3. Decrease stressors
4. Allow patient to rest after major activity

69. 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

70. AIDS DEMENTIA COMPLEX
• 50-70% patient of AIDS
• Triad of cognigtive, behavioral,
motoric deficits, -> subcortical
dementia
• Virus cross Blood Brain Barrier ->
Cognitive impairement
• ELISA, Western Blot
• CT may show cortical atrophy

71. 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,)

72. • The Lesions include:
• Head trauma
• Surgical procedure
• Hypoxia
• Posterior cerebral artery stroke
• Herpes simplex encephalitis

73. 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

74. D. Other Organic Mental Disorders
• Organic Hallucinosis
• Organic Catatonic Disorder
• Organic Delusional (Schizo like)
disorder
• Organic Personality Disorder

75. Organic Hallucinosis
• Persistant or recurrent hallucinations due to an
underlying organic cause.
• No major disruption of consciousness,
intelligence or memory
• Etiology:
• Drugs:Hallucinogens,cocaine,cannabis,bromide)
• Alcohol:In alcoholic hallucinosis,auditory
hallucinations are more common
• Migraine
• Epilepsy: Complex partial seizures
• Brain stem lesions

76. Management
1)Treatment of the underlying cause if treatable.
2) Symptomatic treatment with a low dose of an
anti-psychotic drug.

77. 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

78. Management
• Treatment of underlying cause
• Symptomatic treatment with low doses of
benzodiazipam or an anti-psychotic or
electro convulsive therapy.

79. 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

80. Management
• Treatment of underlying cause
• Symptomatic treatment with low
doses of benzodiazipam or an anti-
psychotic or electro convulsive
therapy.

81. •Frontal lobe damage
•Clinical features:
- behaviour is disinhibited
- overfamiliar
- overtalkative
- inappropriate jokes
- euphoria
- concentration and attention will be
reduced
- insight impaired
Organic personality disorder

86. 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

87. 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

88. 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

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