Organic brain disorders: introduction, definition, causes and risk factors, signs and symptoms, diagnosis and treatment.

1. Organic Brain
Disorders

2. Introduction
 Organic mental disorders are behavioral or psychological
disorders associated with transient or permanent brain
dysfunction and include only those mental and behavioral
disorders that are due to demonstrable cerebral disease or
disorder either primary or secondary

3. Definition of Organic Brain Disorder
 A neuropsychiatric disorder which has a strong
biological basis or a significant brain
dysfunction.

4. Organic Brain Disorder
Delirium Dementia Amnesia
Not otherwise
spoecified
Based on
etiology
Based on
motor
dysfunction
Hyperactive
Hypoactive
Mixed
Primary Secondary
• Organic hallucinations
• Organic delusional
disorder
• Organic mood
disorder
• Organic personality
disorder
• Organic dissociative
disorder

5. The disorder can be subcategorized into the
following categories :
 Delirium
 Dementia
 Organic amnestic syndrome
 Other organic mental disorders

6. Predisposing factors
 Demographic status: presence of age extremes (very old or young) and being
male person.
 Functional status:
 Immobility, history of fails, functional dependent and low performance in
activity.
 Cognitive status: History of delirium, dementia and memory impairment.
 Sensory problems: visual disturbances and hard of hearing.
 Environmental factors: admission in intensive care unit, stress, use of physical
restraints, patients on urinary catheterization, and with sleep disturbance.
 Neurological, endocrine and metabolic disorders: hypothermia, infections,
hypoxia, shock, high fever, anaemia, dehydration, malnutrition,

7. DELIRIUM

8. Definition of Delirium
 According to DSM IV TR delirium is characterized by a disturbance of
consciousness and a change in cognition that develops rapidly over a
period of time.
 An acute confusional state with disturbances in the level of
consciousness and reduced ability to focus, sustain, or shift attention.

9. Epidemiology
 Delirium is a common problem in all health care settings, with
a prevalence of
 0.4% in general population,
 1.1% in general population aged >55 years,
 9–30% in general hospital admissions and
 5–55% in elderly general hospital admissions

10. Predisposing factors
 Metabolic causes
 Endocrine causes
 Drugs (both ingestion and withdrawal causes delirium) and
poisons
 Nutritional deficiencies
 Systemic infections
 Intracranial causes
 Miscellaneous

11. Metabolic causes
 Hypoxia
 Hypoglycaemia
 Hepatic encephalopathy, uremic encephalopathy
 Cardiac failure, cardiac arrhythmias
 Water and electrolyte imbalance(water ,Na+, K+, Mg
++,Ca++)
 Metabolic acidosis
 Fever, anaemia, hypovolemic shock

12. Endocrine causes
 Hypo-hyper pituitairism
 Hypo–hyper–thyroidism
 Hypo-hyper –parathyroidism
 Hypo-hyper –adrenalism

13. Drugs (both ingestion and withdrawal causes
delirium) and poisons
 Digitalis, quinidine, anti-hypertensive’s
 Alcohol, sedatives, hypnotics
 Tri cyclic antidepressants and antipsychotics
 Anti convulsant – levo-dopa
 Salicylates, steroids, penicillin, insulin
 Methyl alcohol, heavy metals

14. Nutritional deficiencies
 Thiamine, niacin, pyridoxine, folic acid ,B12

15. Systemic infections
 Acute and chronic (e.g. septicemia, pneumonia and
endocarditis)

16. Intracranial causes
 Epilepsy
 Head injury, subarachnoid haemorrhage ,sub-dural hematoma
 Intracranial infections e.g. meningitis, encephalitis cerebral
malaria
 Stroke ,hypertensive encephalopathy
 Focal lesions e.g. right parietal lesions

17. Miscellaneous
 Post operative states
 Sleep deprivation
 Heat ,electricity and radiation

18. CLINICAL FEATURES OF DELIRIUM

19. Impairment of consciousness
 There is a continuum between mild impairment of
consciousness and near unconsciousness.

20. Appearance and behaviour
 the patient looks unwell and behavior may be marked by agitation or
hypoactivity, by a fluctuation between these states, or by a mixture of
them—for example, a drowsy patient plucking aimlessly at the
bedclothes.

21. Mood
 frequently labile, with perplexity, intermittent periods of anxiety
or depression, or occasionally of other mood states such as
elation and irritability. Usually, the mood states have an empty
and transitory quality.

22. Speech
 The patient may mumble and be incoherent

23. Perception
 Illusions and misinterpretations are frequent.
 For example, a patient may become agitated and fearful, believing that a shadow in a
dark room is actually an attacker.
 Visual hallucinations occur.
 Auditory and tactile hallucinations also occur.
 Complex sensory distortions, such as colors being experienced as tastes, would suggest
intoxication with hallucinogens

24. Cognition
 There are abnormalities in all areas of cognitive function.
 Memory registration, retention, and recall are all affected.
 Mild cases may show their most pronounced abnormalities in slow
performance on tasks or in the wandering of attention away from the
task at hand

25. Orientation
 In obvious cases, orientation in person, time, and place will all be
disturbed.
 Milder degrees of disorientation will need to be interpreted in the context
of the individual patient.
 For example, it may be considered not abnormal for a person who has
been seriously ill in hospital for a long time to be unaware of the day of
the month.

26. Concentration
 Is impaired, for example, on tests such as ‘serial
sevens' or ‘days of the week backwards'.

27. Memory
 Disturbances are seen, with impaired registration (e.g. digit span), short-term
recall (e.g. name and address), and long-term recall (e.g. current news items).
 After recovery from the illness there is usually (but not always) amnesia for the
illness.

28. Insight
 Is usually impaired. The patient will have no understanding of
why a psychiatric assessment has been requested

29. MANAGEMENT
 Four key steps in management of delirium are –
 Addressing the underlying causes,
 Maintaining behavioral control,
 Preventing complications,
 Supporting functional needs

30. Physical Interventions
 Initial interventions include general measures to support cerebral
function, such as intravenous hydration and appropriate nourishment.
 Supplemental oxygen has been found to be highly effective in patients
who develop delirium with pneumonia.
 Physical restraints, once a mainstay in the treatment of delirium, are
now used only when all pharmacologic and nonpharmacologic
interventions have failed.

31. Environmental Interventions:
 The hospital environment is a significant factor in the management of delirium. Environmental
manipulations are directed toward providing the right amount of stimulation for the patient,
encouraging sleep, maximizing the patient's ability to perceive the environment accurately,
maintaining safety, and achieving familiarity and consistency for the patient.
 Over stimulation should be avoided, because it contributes to both confusion and insomnia
 Under stimulation is probably a more common problem and is perhaps equally injurious.
Delirious patients who are left alone without stimulation often withdraw and begin to
respond more to internal stimuli than external stimuli. In such situations, regular interaction
with hospital staff can be helpful. It is often appropriate to place the delirious patient in a
room close to the nursing station or other workstation

32.  It has long been recognized that, in certain cases, the hallucinations of
delirium can be specifically treated: visual hallucinations by controlled visual
stimuli, auditory hallucinations by music and other meaningful external
sounds, and olfactory hallucinations by the introduction of odors or scents
 To help the patient perceive the environment accurately, adequate daytime
lighting and a night light should be provided
 Hearing aids, eyeglasses and other devices that assist sensory perception
should be used whenever possible and should not be put away during a
delirious episode
 One of the most helpful interventions is having family members stay with the
patient. Family members should also be encouraged to bring personal effects
from home, because some patients with delirium are greatly comforted by
the presence of familiar photographs or objects.

33. Cognitive Interventions
 Reorientation is one of the most easily accomplished cognitive
interventions. The first step is to place a clock and a calendar
where the patient can see them easily. The patient should then
be verbally reoriented to time and place several times over the
course of the day. Repetition is recommended to compensate
for memory impairment in the delirious patient.

34. Psychologic Interventions
 The delusions expressed by a patient should not be
directly disputed. Instead, alternative explanations of
events should be offered, and frequent reassurance
should be given.

35. Pharmacologic Interventions
 100 mg of B1 IV for thiamine deficiency and IV fluids for fluid and
electrolyte imbalances
 Symptomatic management: as many patients are agitated , emergency
psychiatric treatments may be needed. Small doses of
benzodiazepines (lorazepam or diazepam) or antipsychotics
(haloperidol) may be given orally or parenterally

36. PATIENT EDUCATION
 Educating families and patients regarding the etiology and course of
disease is an important role for physicians.
 Educate the patient, family, and primary caregivers about future risk
factors.
 Families may worry that the patient has brain damage or a permanent
psychiatric illness. Providing reassurance that delirium often is temporary
and is the result of a medical condition may be beneficial to both patients
and their families.
 Suggest that family members or friends visit the patient, usually one at a
time, and provide a calm and structured environment. Encourage them to
furnish some familiar objects, such as photos or a favorite blanket, to help
reorient the patient and make the patient feel more secure.