organic mental health disorder

1. Dementia and delirium
Dr. Kamal Ghimire

2. Delirium (Acute confusional state)
• Definition: Acute onset of global but fluctuating cognitive
dysfunction, due to an underlying cause.
• Delirium is more likely to occur in children, when the brain is still
developing, and in the elderly, when the brain is starting to
degenerate.

3. Clinical features
• Hypoactive: withdrawn, quiet, sleepy.
• Hyperactive: restless, agitated and agressive
• Hallucinations, delusions (often persecutory)
• Autonomic hyperactivity: sweating, tachycardia
and dilated pupils
Fluctuating confusion and attention
Worse at night- sundowning.

4. Etiology
High risk groups:
• Aged 65 years and over
• People with diffuse brain disease
• Current hip fracture
• Severely ill
Pathophysiology
• Breakdown of blood brain barrier
• Dopaminergic excess
• hypercortisolemia

5. Assessment
• History and examination
• Investigations:
Blood: CBC( exclude anemia, macrocytosis, leukocytosis), ESR, LFT,
Glucose, TFT, LFT, Calcium, folate and vitamin B 12, VDRL
Urine: Routine and microscopy
Chest X ray
CT/MRI
EEG ( if epilepsy is differential)

6. Management
• Identify cause and treatment
• If a patient is distressed or considered a risk to him/herself or others:
1. Short term (<1 week) antipsychotic( eg. Haloperidol) or short acting
benzodiazepines ( lorazepam)

7. Preventing delirium

8. Dementia
• It is acquired, progressive, (usually) irreversible global deterioration of
higher cortical function in clear consciousness resulting in impairment
of daily activities.
• Presentation may occur months or years after the onset of symptoms
and is often at family instigation because the person frequently
has no insight into his or her deterioration. The clinical
presentation may vary between different types of dementia.

9. Features and diagnostic requirement

10. Classification

11. Etiology

12. Alzheimer's disease (most common cause)
Apolipoprotein E (ApoE) gene contributing most to the genetic aetiological component

13. Alzheimer's disease- Clinical features
• Initial: Gradual memory impairment. Short term/recent memory.
• Later: Long term memory, apraxia (loss of ability to execute or carry
out skilled movements and gestures despite having desire and ability
to perform them), visio-spatial impairment, aphasia.
• Disorientation, bedridden, infection and death.

14. • Vascular dementia: stepwise deterioration rather than continuous
Pathologically, there is at least one area of cortical infarction. There
is a ninefold increase in risk of dementia in the year after a stroke.
Vascular risk factors such as hypertension, hypercholesterolaemia,
diabetes and smoking are risk factors for both vascular dementia and
AD.
• Dementia with lewy bodies: Dementia with Lewy bodies (DLB) is
characterised by fluctuating cognition and alertness, vivid visual
hallucinations, spontaneous parkinsonism, sensitivity to neuroleptic
medication and a sleep disorder.
• Frontotemporal dementia: It is characterised by early personality
changes and relative intellectual sparing.
• Normal pressure hydrocephalous: It presents with marked mental
slowness, apathy, wide-based gait and urinary incontinence.(wet,
wacky, wobbly grandpa.

15. Management
• Assess History, MSE and rule out the possibility of treatable acute
confusional state ( similar investigation as delirium)
• In Alzheimers disease: cholinesterase inhibitors ( donepezil,
rivastigmine, galantamine), NMDA (glutamate) antagonist:
memantine.
• Treatment of neuropsychiatric symptoms.
• Social support
• Cognitive stimulation/ behavioural management techniques.

16. Delirium vs Dementia

17. Thank you