Organic Disorders

ORGANIC DISORDERS
PRESENTED BY:
MS. MONIKA KANWAR
M.SC. (N) MENTAL HEALTH NURSING
NURSING TUTOR

INTRODUCTION
• Cognitive disorders include those in which a clinically significant
deficit in cognition or memory exist, representing a significant
change from a previous level of functioning.
• Organic Brain Syndrome (OBS) also known as Organic Brain
Disease (OBD) refers to the physical disorders that cause impaired
mental function especially in the cognitive domain.
• Originally, the term was created to distinguish physical (termed
organic) causes of mental impairment from psychiatric (termed
functional) disorders.
• The DSM-IV-TR (American Psychiatric Association, APA, 2000)
describes the etiology of these disorders on a general medical
condition, a substance or a combination of these factors.

DEFINITION
• Organic Mental Disorders are disturbances that may be
caused by injury or disease affecting brain tissues as well as
by chemical or hormonal abnormalities. Exposure to toxic
materials, neurological impairment, or abnormal changes
associated with aging can also cause these disorders.
OR
• Organic Mental Disorders, also known as Organic Brain
Syndrome, Organic Brain Disease, Organic Mental
functions whose cause is alleged to be known as organic
(Physiologic).

ORGANIC PSYCHOSIS
• An organic psychosis are characterised by abnormal brain
function with a known physical cause characterized by an
altered perception of reality
OR
• American Psychiatric Association defines organic
psychosis/ organic brain syndrome “a mental disorder
characteristically resulting from diffuse impairment of brain
tissue function from any cause”.

TYPES/CLASSIFICATION OF
ORGANIC MENTAL DISORDERS
TYPES
Acute Organic
Mental
Disorder
(Delirium)
Chronic
Organic Mental
Disorder
(Dementia)
Organic
amnestic
syndrome
Other organic
mental
disorders

CONTD….
• Acute Organic Mental Disorders: “Acute” means “of recent onset”
and often temporary (Delirium)
• Chronic Organic Mental Disorders: Persist for longer time and
may leads to permanent brain damage (Dementia).
• Amnesia: It usually refers to the temporary loss of memory and
may caused by various organic conditions such as head and brain
injuries, drugs, alcohol, traumatic events, etc.
• Other Organic Mental Disorders: It includes hallucinations,
delusions, personality disorders, mood disorders, dissociative
disorders caused by some underlying organic conditions.

CONTD….
DSM-5 described Six Cognitive Domains which may be affected in
both minor and major neurocognitive disorders that includes:
• Complex Attention: Attention and Information processing
• Executive ability: Planning, decision making, working, memory,
responding to feedback, error correction, overriding habits and
mental flexibility.
• Learning and memory: Immediate, recent and remote
• Language: Involves expressive language (naming, fluency,
grammar and syntax) and receptive language.
• Perceptual-motor, visual perception, praxis: Involves picking up to
the telephone, handwriting, using a fork/spoon.
• Social cognition: Recognition of emotions and behavioral
regulation, social appropriateness in terms of dress, grooming and
topics of conversation.

ETIOLOGY
• V – Vascular: Hypertension, intracranial haemorrhage, shock etc.
• I – Infective (Temporary): Meningitis, encephalitis
• N – Neoplastic: Brain space occupying lesions
• D – Degenerative: Parkinson’s disease, Alzheimer’s Disease,
Huntington disease and multiple sclerosis may also be
contributing factors.
• I – Intoxication (Temporary): Drug intoxication such as opiates,
benzodiazepines, sedatives, etc.
• C – Congenital: Epilepsy, Aneurysm
• T – Traumatic: Brain Hematoma, Injury, Lacerations

CONTD….
• I – Intraventricular: Hydrocephalus
• V – Vitamin Deficiency (Temporary): Deficiency of thiamine,
niacin, B12
• E – Endocrine: Myxedema, Diabetic acidosis/Coma, Uremia,
Hyperthyroidism, Electrolyte imbalance, autoimmune
disorders, Parathyroid dysfunction.
• M – Metabolic intoxication: Toxins such as lead, mercury,
carbon monoxide
• A – Anoxic: Anoxia and Hypoxia
• D – Depression (Temporary): Depression

SUSPECT ORGANIC IF…..
The presence of following features requires a high index of suspicion
for an organic mental disorder (or what is loosely called as organicity)
1. First episode
2. Sudden onset
3. Older age of onset
4. History of drug and/or alcohol use disorder.
5. Concurrent medical or neurological illness.
6. Neurological symptoms or signs, such as seizures, impairment of
consciousness, head injury, sensory or motor disturbance.
7. Presence of confusion, disorientation, memory impairment or soft
neurological signs.
8. Prominent visual or other non-auditory (e.g. olfactory, gustatory or
tactile) hallucinations.

DIAGNOSIS
• Complete medical history
• Family History and Personal History
• History of Premorbid Personality
• Mental Status Examination/ Mini Mental Status Examination,
Neurological and Physical examination
• Special Investigation: Computerized Axial Tomography (CAT)
Scan, biochemical, hematologic and ECG
• Lab test: Complete blood count, serological test for syphilis,
electrolytes, blood urea nitrogen, blood sugar, liver function tests,
thyroid function tests, vitamin B12 and folate levels, calcium and
phosphorus levels, urinalysis, etc.

CLASSIFICATION
ICD-10 CLASSIFICATION
F00-F09 Organic, including symptomatic mental disorders
F00 Dementia in Alzheimer’s disease
F01 Vascular Dementia
F02 Dementia in other disease classified elsewhere
F03 Unspecified Dementia
F04 Organic amnestic syndrome, not induced by alcohol and other
psychoactive substances
F05 Delirium not induced by Alcohol and other psychoactive substances
F06 Other mental disorders due to brain damage and dysfunction and to
physical disease
F07 Personality and behavioral disorders due to brain disease, damage and
dysfunction
F09 Unspecified organic or symptomatic mental disorder

CONTD….
F00 Dementia in Alzheimer’s disease
F00.0 Dementia in Alzheimer’s disease with early onset
F00.1 Dementia in Alzheimer’s disease with late onset
F00.2 Dementia in Alzheimer’s disease, atypical or mixed type
F00.9 Dementia in Alzheimer’s disease, unspecified
F01 Vascular Dementia
F01.0 Vascular Dementia of acute onset
F01.1 Multiple Infarct Dementia
F01.2 Subcortical Vascular Dementia
F01.3 Mixed cortical and subcortical Vascular Dementia
F01.8 Other Vascular Dementia
F01.9 Vascular Dementia, unspecified

CONTD….
F02 Dementia in other disease classified elsewhere
F02.0 Dementia in Pick’s disease
F02.1 Dementia in Creutzfeldt-Jakob disease
F02.2 Dementia in Huntington disease
F02.3 Dementia in Parkinson’s disease
F02.4 Dementia in HIV disease
F02.8 Dementia in other specified disease classified elsewhere
F03 Unspecified Dementia
F03.0 Without additional symptoms
F03.1 Other symptoms, predominantly delusional
F03.2 Other symptoms, predominantly hallucinatory
F03.3 Other symptoms, predominantly depressive
F03.4 Other Mixed symptoms

DEMENTIA
• Other terms used to describe dementia:
- Chronic organic brain syndrome
- Chronic organic mental disorder
• Dementia (taken from Latin, Original meaning “Madness”, De
– without + ment – the root of mens “mind”)
• Dementia is a chronic and progressive disease characterized by
the gradual, progressive and chronic deterioration (Decline) of
memory and intellectual functioning (judgement orientation,
memory and emotional stability) of the affected person.

DEFINITION
Dementia is defined by loss of previous level of cognitive,
executive and memory function in a state of full alertness.
(Bourgeois, et al. 2008)
OR
Dementia is a syndrome resulting from acquired brain disease.
It is characterized by a progressive decline in memory and other
cognitive domains that, when severe enough, interferes with
daily living and independent functioning.
(DSM-5, American Psychiatric Association, APA, 2013)

EPIDEMIOLOGY (WHO, 2019)
• Worldwide, around 50 million people are suffering from
dementia, with nearly 60% living in low and middle income
countries.
• 10 million new cases are detected every year.
• The estimated proportion of the general population aged 60 and
over with dementia at a given time between 5% and 8%.
• The total number of people with dementia is projected to reach
82 million in 2030 and 152 million in 2050.
• Alzheimer disease is the most common form of dementia and
may contribute to 60-70% of cases of dementia.
• Neither gender nor literacy was associated with the prevalence
of Dementia.

CLINICAL FEATURES
Dementia is not a single disease, but rather a nonspecific illness
syndrome (i.e. set of signs and symptoms) in which affected areas of
cognition may be memory, attention, language, and problem solving.
It is normally required to be present for atleast 6 months to be
diagnosed.
• Loss of intellectual abilities resulting in interference of social and
occupational functioning.
• Memory loss (usually insidious and progressive, sometimes
reversible).
• Impaired abstract thinking and judgement
• Disturbed higher cortical functions (aphasia, apraxia and agnosia)
• Constructional difficulty (inability to cope three dimensional figures,
assemble blocks or arrange sticks
• Depression

CONTD….
Disturbed
Higher
cortical
function
Aphasia (Loss of language
comprehension or production)
Apraxia ( Loss of ability
to perform skilled motor
act)
Agnosia (Loss of ability to
recognize objects)

CONTD….
Other Symptoms of Dementia (American Psychiatric
Association, 1997)
• Disinhibited (Tactless, rude) behavior such as making
inappropriate jokes.
• Neglecting personal hygiene
• Exhibiting excessive familiarity with strangers
• Suicidal behavior among who have insight into their deficits.
• Depressed mood and sleep disturbances
• Delusions (persecution and misidentification)
• Hallucinations (Visual)
• Sundowning (A peak period of agitation during the evening
hours)

CONTD….
• Anxiety and catastrophic reactions (overwhelming emotional
response to relatively minor stressors such as changes in
routine or environment).
• Motor disturbances (gait difficulties, slurred speech, and
abnormal movements)
• Other neurological symptoms (myoclonus and seizures)

TYPES OF DEMENTIA
1. Presenile Dementia:
Occurs before the age of 65 years.
2. Senile Dementia:
Has an onset after 65 years of age.
3. Primary Dementia:
Primary Dementia are those such as Alzheimer’s Dementia, in
which the dementia itself is the major sign of some organic
brain disease not directly related to any other organic illness.

CONTD….
4. Secondary Dementia
Secondary Dementia are caused by or related to another
disease or condition, such as HIV disease or cerebral trauma.
5. Cortical Dementia:
It is caused by the Alzheimer’s and Pick’s disease and affects
the cerebral cortex of brain. It is characterized by the more
severe intellectual and memory dysfunction in the presence of
aphasia, agnosia and apraxia.

CONTD….
6. Subcortical Dementia
It is caused by the degenerative dysfunction of subcortical
brain regions such as substantia nigra, striatum and Globus
pallidus. It is mainly caused by the organic disease, Jakob
disease, Wilson’s disease, etc. It involves less severe
intellectual and memory dysfunction in the absence of
aphasia, agnosia and apraxia.
7. Progressive Dementia:
Dementia that gets worse overtime, gradually interfering with
more and more cognitive abilities.

CONTD….
8. Frontotemporal Dementia
Frontotemporal Dementia refers to a group of brain disorders
that primarily affect the frontal and temporal lobes of the
brain. Shrinkage of these lobes are generally associated with
personality, behavior and language.

CONTD….
1. Stage:1 - No apparent Symptoms/No impairment:
Stage one represents no impairment in the abilities of patient.
Patients have no significant memory problems, are fully
oriented to time, place, have normal judgement, can function
out in the world, have a well-maintained home life and are
fully able to take care of their personal needs.

CONTD….
2. Stage:2 - Forgetfulness/Questionable impairment:
- In this stage, individual begins to lose things or forget names
of people.
- Loses in short term memory are common.
- Individual is aware of the intellectual decline and may feels
ashamed, becoming anxious and depressed which in turn
may worsen the symptoms.
- These symptoms are often not observed by others.
- At this stage, patient can still manage their own care without
any help.

CONTD….
3. Stage:3 - Mild cognitive decline/Mild impairment:
- In this stage, there is interference with work performance
which becomes noticeable to co-workers.
- Concentration may be interrupted.
- The individual may get lost while driving his/her car.
- There is difficulty in recalling names or words which
becomes noticeable to family and close associates.
- A decline occurs in the ability to plan or organize.

CONTD….
4. Stage:4 - Mild to moderate cognitive decline(Confusion)
/Moderate impairment:
- At this stage, individual may forget major events in personal
history such as his/her own child’s birthday, decline ability
to perform tasks, such as shopping and managing personal
finances, or be unable to understand current new events.
- He or she may deny that a problem exists by covering up
memory loss with Confabulation (creating imaginary events
to fill in memory gaps)
- Depression and social withdrawal are common.

CONTD….
5. Stage:5 - Moderate cognitive decline (Early Dementia) :
- In this stage of dementia, individuals lose the ability to
perform some Activity of Daily Living (ADLs)
independently, such as hygiene, dressing and grooming and
require some assistance to manage these on an ongoing
basis.
- They may forget address, phone no. and name of close
relatives. They may become disoriented about place and
time but they maintain knowledge about themselves.
- Frustration, withdrawal and absorption are common.

CONTD….
6. Stage:6 - Moderate to severe cognitive decline (Middle
Dementia):
- In this stage of dementia, individual may be unable to recall
recent major life events or even the name of his/her spouse.
- Disorientation to surrounding is common and the person
may be unable to recall the day, season or year.
- The person is unable to manage Activity of Daily Living
without any assistance. Urinary and faecal incontinence are
common. Sleeping becomes a problem.
- Symptoms seems to be worsen in the late afternoon and
evening- a phenomenon termed as Sun-downing.
- Psychomotor symptoms include wandering, obsessiveness,
agitation and aggression.

CONTD….
7. Stage:7 - Severe cognitive decline (Late Dementia)/ Severe
impairment:
- In the end stage, the individual is unable to recognize family
members. He or she most commonly is bedfast and aphasic.
- Problems of immobility, such as decubiti's and contractures may
occur.
- Stanely and Associates (2005) describe the late stage of
dementia in following manner:
The person become more chair bound or bedbound.
Muscles are rigid, contractures may develop and primitive
reflexes may be present.
The person may have very active hands and repetitive
movements, grunting or other vocalizations.

CONTD….
There is depressed immune system function and this
impairment coupled with immobility may lead to the
development of pneumonia, UTI, sepsis and pressure ulcers.
Appetite decreases and dysphasia is present, aspiration is
common.
Weight loss generally occurs.
Speech and language are severely impaired with greatly
decreased verbal communication.
The person may no longer recognize any family members.
Bowel and bladder incontinence are present and caregivers
need to complete most Activity of Daily Livings for the
person.

CONTD….
The sleep wake cycle is greatly altered, and the person spends a lot of
time dozing and appears socially withdrawn and more unaware of the
environment or surroundings.
Death may be caused by infection, sepsis or aspiration, although there
are not many studies examining cause of death.

PREDISPOSING FACTORS
The disorders of Dementia are differentiated by their etiology,
although they share a common symptoms presentation.
CATEGORIES OF DEMENTIA INCLUDE
1. Dementia of the Alzheimer’s type
2. Vascular dementia
3. Dementia due to HIV disease
4. Dementia due to head trauma
5. Dementia due to Lewy body disease
6. Dementia due to Parkinson’s Disease

CONTD….
7. Dementia due to Huntington’s disease
8. Dementia due to Pick’s disease
9. Dementia due to Creutzfeldt–Jakob disease
10. Dementia due to other general medical conditions
11. Substance-induced persisting dementia
12. Dementia due to multiple etiologies

CONTD….
1. Dementia of Alzheimer’s Type:
• The onset of symptoms is slow and insidious and the course of
the disorder is generally progressive and deteriorating.
• Examination by CT scan or MRI reveals a degenerative
pathology of the brain that includes atrophy, widened cortical
sulci, and enlarged cerebral ventricles.
- Microscopic Examination reveals numerous neurofibrillary
tangles and senile plaques in the brains of clients with Alzheimer
Disease.
ETIOLOGY:
The exact cause of Alzheimer Disease is unknown. Several
hypothesis have been supported by varying amounts and qualities
of data. These hypothesis include:

CONTD….
i. Acetylcholine Alterations:
- Research has indicated that in the brain of Alzheimer Disease
clients, the enzyme required to produce acetylcholine is
dramatically reduced.
- The decrease in production of acetylcholine reduces the amount
of the neurotransmitter that is released to cells in the cortex and
hippocampus, resulting in a disruption of the cognitive processes.
- Other neurotransmitters implicated in the pathology and clinical
symptoms of Alzheimer’s Disease include nor-epinephrine,
serotonin, dopamine and the amino acid glutamate.
- It has been proposed that in Dementia, excess Glutamate leads to
overstimulation of the N-methyl-D-Aspartate (NMDA) receptors,
leading to increased intracellular calcium, and subsequent
neuronal degeneration and cell death.

CONTD….
ii. Plaques and Tangles:
- An overabundance of structures called plaques and tangles
appears in the brains of the individual with Alzheimer Disease.
- The plaques are made of a protein called Amyloid beta (AB),
which are fragments of a larger protein called Amyloid precursor
protein.
- Plaques are formed when these fragments clump together and mix
with molecules and other cellular matter.
- Tangles are formed from a special kind of cellular protein called
Tau Protein, whose function is to provide stability to the neuron.
- In Alzheimer Disease, the tau protein is chemically altered.
- Strands of the protein become tangled together, interfering with
the neuronal transport system.

CONTD….
iii. Head Trauma:
- The etiology of Alzheimer Disease has been associated with
serious head trauma.
- Studies have shown that some individuals who had experienced
head trauma had subsequently (after years) developed
Alzheimer Disease.
- Munaz and Feldman (2000) report an increased risk for
Alzheimer Disease in individuals who are both genetically
predisposed and who experience traumatic head injury.

CONTD….
iv. Genetic Factors:
- There is clearly a familial pattern with some forms of
Alzheimer Disease.
- Some families exhibit a pattern of inheritance that suggests
possible autosomal dominant gene transmission.
- People with Down Syndrome, who carry an extra copy of
Chromosome 21, have been found to be unusually susceptible
to Alzheimer Disease.

CONTD….
2. Vascular Dementia:
• In Vascular Dementia, the clinical syndrome of Dementia is
due to significant cerebrovascular disease. The blood vessels of
the brain are affected and progressive intellectual deterioration
occurs.
• Vascular Dementia is the 2nd most common form of Dementia,
ranking after Alzheimer Disease.
ETIOLOGY:
The cause of Vascular Dementia is directly related to an
interruption of blood flow to brain, leads to death of nerve cells.

CONTD….
i. Hypertension:
- It leads to damage of the lining of the blood vessels. This can
result in rupture of the blood vessels with subsequent
haemorrhage or an accumulation of fibrin in the blood vessel with
intravascular clotting and inhibited blood flow leads to multiple
small strokes or cerebral infarcts.
ii. Cognitive Impairment:
- It can occur with multiple small infarcts (sometimes called Silent
strokes) overtime or with a single cerebrovascular insult that
occur in strategic area of the brain.
- An individual may have both vascular Dementia and Alzheimer
Disease simultaneously.

CONTD….
3. Dementia Due to Human Immunodeficiency Virus (HIV):
• Infection with Human Immunodeficiency Virus-type I (HIV-I)
produced a dementing illness called HIV associated Dementia
(HAD).
• The immune dysfunction associated with HIV disease can lead
to brain infection, and appears to cause dementia directly.
• In the early stages, neuropsychiatric symptoms may be
manifested.
• Severe cognitive changes, particularly confusion, changes in
behavior and sometimes psychosis are not uncommon in later
stages.

CONTD….
4. Dementia Due to Head Trauma:
• Serious Head Trauma can result in symptoms associated with
the syndrome of Dementia.
• Amnesia is the most common neurobehavioral symptom
following head trauma, and a degree of permanent disturbance
may persist.
• Repeated Head Trauma such as the type experienced by boxers
can result in Dementia Pugilistic, a syndrome characterized by
emotional liability, dysarthria, ataxia and impulsivity.

CONTD….
5. Dementia Due to Lewy Body Disease:
• This disorder is distinctive by the presence of Lewy Bodies
(Abnormal balloon like clumps of protein) eosinophilic
inclusion bodies seen in the cerebral cortex and brainstem.
• However, it tends to progress more rapidly and there is earlier
appearance of visual hallucinations and Parkinsonian Features.
• These patients are highly sensitive to extra pyramidal effects of
Antipsychotic medications.
• The disease is progressive and irreversible and may account for
as many as 25% of all dementia cases.

CONTD….
6. Dementia Due to Parkinson’s Disease:
• Dementia is observed in as many as 60% of clients with
Parkinson’s disease.
• In this disease, there is loss of nerve cells located in the
Substantia Nigra and Dopamine activity is diminished,
resulting in involuntarily muscle movements, slowness and
rigidity.
• Tremor in the upper extremities.
• In some instances, the cerebral changes that occur in Dementia
of Parkinson’s Disease closely resemble those of Alzheimer
Disease.

CONTD….
7. Dementia Due to Huntington’s Disease:
• Damage is seen in the areas of the Basal Ganglia and the
Cerebral Cortex.
• The onset of symptoms (i.e. voluntary twitching of the limbs or
facial muscles, mild cognitive changes, depression and apathy)
usually between ages 30 to 50 Years.
• The client usually declines into a profound state of Dementia
and Ataxia.

CONTD….
8. Dementia Due to Pick’s Disease:
• Studies reveal that pathology of Pick’s Disease results from
atrophy in the frontal and temporal lobes of the brain.
• The cause of Pick’s Disease is unknown but a genetic factor
appears to be involved.
• The clinical picture is strikingly similar to that of Alzheimer
Disease.
• Others like personality change, whereas the initial symptom in
Alzheimer Disease is memory impairment.

CONTD….
9. Dementia Due to Creutzfeldt-Jakob Disease:
• Creutzfeldt Jakob Disease is an uncommon neurodegenerative
disease caused by a transmissible agent known as “Slow Virus”
or Prion (abnormal infectious of protein in the brain).
• 5 to 15% of cases have a genetic component.
• Symptoms like syndrome of dementia, along with involuntary
movements, involuntary rigidity and Ataxia.
• Symptoms may develop between ages 40 to 60 Years.
• The clinical course is extremely rapid, with progressive
deterioration leading to dementia, akinetic mutism, coma and
death within 1 year.

CONTD….
10. Dementia Due to General Medical conditions:
• A number of other general medical conditions can cause
Dementia.
• Some of these includes endocrine conditions (Hypoglycaemia,
hypothyroidism), pulmonary disease, hepatic or renal failure,
cardiopulmonary insufficiencies, fluid and electrolytes
imbalances, nutritional deficiencies, frontal and temporal lobe
lesions, central nervous system or systemic infections,
uncontrolled epilepsy, and other neurological conditions such
as multiple sclerosis (APA, 2000)

CONTD….
11. Substance-Induced Persisting Dementia:
• DSM-IV-TR identifies the following types of substances with
which persisting Dementia is associated:
- Alcohol
- Inhalants
- Sedatives, hypnotics and anxiolytics
- Medications
- Anticonvulsants
- Intrathecal Methotrexate
- Toxins
- Lead

CONTD….
- Mercury
- Carbon monoxide
- Organophosphate insecticides
- Industrial solvents.
• The diagnosis is made according to specific etiological
substance involved.
• For example if the substance known to cause the dementia is
Alcohol, thus the diagnosis is Alcohol induced persisting
Dementia.

CONTD….
12. Dementia Due to Multiple Etiology:
• The diagnosis is used when the symptoms of Dementia are
attributed to more than one cause.
• For example the dementia may be related to more than one
medical condition or in the combined effects of General
Medical Condition and the long term use of a substance.

SOME COMMON CAUSES OF
DEMENTIA
• PARENCHYMATOUS BRAIN DISEASE
- Alzheimer’s disease
- Pick’s disease
- Parkin son’s disease
- Huntington’s chorea
- Lewy body dementia
- Steel Richardson syndrome (Progressive Supranuclear Palsy)

CONTD….
• VASCULAR DEMENTIA
- Multi-infarct dementia
- Subcortical vascular dementia ( Binswanger’s disease)
• TOXIC DEMENTIAS
- Bromide intoxication
- Drugs & Alcohol
- Heavy metal
- carbon monoxide
- Analgesics
- Anticonvulsants
- Benzodiazepines and psychotropic drugs

CONTD….
• METABOLIC DEMENTIAS
- Chronic hepatic or uraemic encephalopathy
- Dialysis dementia
- Wilson’s disease
• ENDOCRINE CAUSES
- Thyroid, parathyroid, pituitary, adrenal dysfunction

CONTD….
• DEFICIENCY DEMENTIAS
- Pernicious anaemia
- Pellagra
- Folic acid deficiency
- Thiamine deficiency
• DEMENTIAS DUE TO INFECTIONS:
- Creutzfeldt-Jacob disease
- Neurosyphilis
- Chronic meningitis and Viral encephalitis
- AIDS dementia and Other HIV-related disorders
- Sub acute sclerosingpanencephalitis (SSPE)

CONTD….
• NEOPLASTIC DEMENTIAS
- Neoplasms and other intracranial space-occupying lesions
• TRAUMATIC DEMENTIAS
- Chronic subdural haematoma
- Head injury
• HYDROCEPHALIC DEMENTIA
- Normal pressure hydrocephalus

SIGN AND SYMPTOMS OF
DEMENTIA
Dementia symptoms vary depending on the causes, but common
signs and symptoms include:
COGNITIVE CHANGES:
• Memory loss, which is usually notices by a spouse or someone
else.
• Difficulty communicating or finding words.
• Difficulty with visual and spatial abilities, such as getting lost
while driving
• Difficulty in reasoning or problem solving
• Difficulty in handling complex tasks
• Difficulty with planning and organizing
• Difficulty with coordination and motor function

CONTD….
• Confusion and disorientation
PSYCHOLOGICAL CHANGES:
• Personality changes
• Depression
• Anxiety
• In appropriate behavior
• Paranoia
• Agitation
• Hallucinations

CONTD….
ADDITIONAL SYMPTOMS:
• Emotional liability (marked variation in emotional expression)
• Catastrophic reaction (when confronted with an assignment
which is beyond the residual intellectual capacity, patient may
go into a sudden range).
• Thought abnormalities, e.g. Perseveration, delusions.
• Urinary and faecal incontinence may develop in later stages.
• Neurological signs may or may not be present, depending on
the underlying cause.

CONTD….
SYMPTOMS SPECIFIC TO ALZHEIMER’S DISEASE:
• Personality changes: lack of interest in day-to-day activities,
easy mental fatigability, self centered, withdrawn, decreased
self-care
• Memory impairment: recent memory is prominently affected
• Cognitive impairment: disorientation, poor judgment, difficulty
in abstraction, decreased attention span
• Affective impairment: labile mood, irritableness, depression.
• Behavioral impairment: stereotyped behavior, alteration in
sexual drives and activities, neurotic/psychotic behavior.
• Neurological impairment: aphasia, apraxia, agnosia, seizures,
headache

CONTD….
• Catastrophic reaction: Agitation, attempt to compensate for
defects by using strategies to avoid demonstrating failures in
intellectual performances, such as changing the subject,
cracking jokes or otherwise diverting the interviewer
• Sundowning syndrome: It is characterized by drowsiness,
confusion, ataxia; accidental falls may occur at night when
external stimuli such as light and interpersonal orienting cues
are diminished.
• Becoming more withdrawn or anxious.

CONTD….
SYMPTOMS SPECIFIC TO VASCULAR DEMENTIA:
Specific symptoms can include:
- Stroke like symptoms including muscle weakness or temporary
paralysis on one side of the body (these symptoms require
urgent medical attention).
- Movement problems: Difficulty walking or a change in the way
a person walks.
- Thinking problems: Having difficulties with attention, planning
and reasoning.
- Mood changes: Depression and a tendency to become more
emotional.

CONTD….
SYMPTOMS SPECIFIC TO DEMENTIA WITH LEWY
BODIES:
- Periods of being alert or drowsy, or fluctuating levels of
confusion.
- Visual hallucinations
- Becoming slower in their physical movements
- Repeated falls and fainting
- Sleep disturbances.

CONTD….
SYMPTOMS SPECIFIC TO FRONTOTEMPORAL
DEMENTIA:
Early symptoms of frontotemporal Dementia may include:
- Personality changes: Reduced sensitivity to other’s feelings,
making people seen cold and unfeeling.
- Lack of Social awareness: Making inappropriate jokes or
showing a lack of tact, though some people may become very
withdrawn and apathetic
- Language problems: Difficulty finding the right words or
understanding them.
- Becoming obsessive: Such as developing fads for unusual
foods, overeating and drinking.

CONTD….
SYMPTOMS SPECIFIC TO LATER STAGE DEMENTIA:
The most common symptoms of Advanced Dementia include:
- Memory Problems: People may not recognize close family and
friends, or remember where they live or where they are.
- Communication problems: Some people may eventually lose
the ability to speak altogether. Using non-verbal means of
communication, such as facial expression, touch and gestures
can help.
- Mobility problems: Many people become less able to move
about unaided. Some may eventually become unable to walk
and require a wheelchair or be confined to bed.

CONTD….
- Behavioral problems: A significant number of people develop
what are known as “Behavioral and psychological symptoms of
Dementia”. These may include Increased agitation, depressive
symptoms, anxiety, wandering, aggression or sometime
hallucinations.
- Bladder Incontinence: It is common in the later stages of
Dementia, and some people will also experience bowel
incontinence.
- Appetite and weight loss problems: These are both common in
advanced Dementia. Many people have trouble eating or
swallowing and this can lead to choking, infections and other
problems.

DIAGNOSTIC CRITERIA
ACCORDING TO DSM-5
A. Evidence of significant cognitive decline from a previous
level of performance in one or more cognitive domains:
• Learning and memory
• Language
• Executive function
• Complex attention
• Perceptual-motor
• Social cognition

CONTD….
B. The cognitive deficits interfere with independence in
everyday activities. At a minimum, assistance should be
required with complex instrumental activities of daily living,
such as paying bills or managing medications
C. The cognitive deficits do not occur exclusively in the
context of a delirium.
D. The cognitive deficits are not better explained by another
mental disorder (e.g. major depressive disorder,
schizophrenia).

DIAGNOSIS
• Medical history
• Laboratory Testing:
- Routine blood tests
- Vitamin B12, Folic Acid, Thyroid Stimulating Hormone (TSH)
- C-reactive protein (CRP), electrolytes, calcium, renal function
and liver enzymes.
- Urine test to test various infections

CONTD….
• Cognitive Testing:
- Mental Status Examination
- Mini Mental Status Examination (MMSE)
- Cognitive abilities screening instrument (CASI)
• Imaging:
- EEG, which measures and records the brain’s electrical activity
- CT scan, an image of the size and shape of the brain can be
obtained
- MRI is used to obtain a computerized image of soft tissue in the
body. It provides a sharp detailed picture of the tissues of the
brain
- SPECT is more useful in assessing long-standing cognitive
dysfunction.

CONTD….
- PET is used to reveal the metabolic activity of the brain.
Others:
- Lumbar Puncture may be performed to examine the
cerebrospinal fluid for evidence of CNS infection or
haemorrhage.
- In recent study at University of California Los Angeles,
researchers used PET following injections of FDDNP (a
molecule that binds to plaques and tangles in vitro)
- With this test, the researchers were able to distinguish between
subjects with Alzheimer’s Disease, mild cognitive impairment,
and those with no cognitive impairment.

CONTD….
- With FDDNP-PET, researchers are able to accurately
diagnose Alzheimer’s Disease in its earlier stages and track
disease progression noninvasively in a clinical setting.
- Neurological reflexes- Reflexes, co-ordination and balance,
muscle tone and strength, eye movement, speech and
sensation.
- Brain Biopsy: Brain needle biopsy is used to diagnose a
variety of disorders: Alzheimer's disease, autoimmune
encephalopathies, and tumors. It is conducted stereotactically
and indicated when no other investigative techniques such as
MRI or lumbar puncture have been sufficient to make a
diagnosis.

DEMENTIA PREVENTION
Research reported at 2019 Alzheimer’s Association
International Conference suggests that adopting multiple
healthy lifestyle choices, including:
• Healthy diet
• Not smoking
• Regular exercise
• Cognitive stimulation
These may decrease the risk of cognitive decline and
Dementia.

TREATMENT
DRUG CLASSIFICATION FOR TREATMENT OF
Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
Memantine (Namenda)
Cholinesterase Inhibitor
NMDA Receptor Antagonist
Cognitive Impairment
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Haloperidol (Haldol)
Antipsychotic
Antipsychotic
Antipsychotic
Antipsychotic
Agitation, aggression,
hallucinations, thought
disturbances, wandering
Sertraline (Zoloft)
Paroxetine (Paxil)
Nortriptyline (Pamelor)
Antidepressants (SSRI)
Antidepressants (SSRI)
Antidepressant (Tricyclic)
Depression
Depression
Depression

CONTD….
DRUG CLASSIFICATION FOR TREATMENT OF
Lorazepam (Ativan)
Oxazepam (Aricept)
Antianxiety (Benzodiazepines)
Antianxiety (Benzodiazepines)
Anxiety
Anxiety
Temazepam (Restoril)
Zolpidem (Ambien)
Zaleplon (Sonata)
Sedative/Hypnotic (Benzodiazepine)
Insomnia
Insomnia
Insomnia
Trazodone (Desyrel)
Mirtazapine (Remeron)
Antidepressants (Heterocyclic)
Antidepressants (Tetracyclic)
Depression and insomnia
Depression and insomnia

PSYCHOSOCIAL INTERVENTION
These specific psychosocial treatments for dementia can be
divided into four broad groups as described below (American
Psychiatric Association, 1997):
• Behavior-Oriented Approach:
- Assessment of specific triggers of problem behavior
- Avoid acting out behavior whenever possible.
- Alter the environment so that the negative consequences are
minimized.
- Simplify the complex activities such as dressing and eating by
breaking them into parts.

CONTD….
• Emotion-Oriented Approach:
- These interventions include supportive psychotherapy,
reminiscence therapy, validation therapy, sensory integration and
stimulated presence therapy.
-Supportive Psychotherapy: Supportive therapy is a form of
psychotherapy that relies on the therapeutic alliance to alleviate
symptoms, improve self-esteem, restore relation to reality,
regulate impulses and negative thinking, and reinforce the ability
to cope with life stressors and challenges.

CONTD….
• Reminiscence Psychotherapy: It is a treatment that uses all the
senses- sight, touch, taste, smell and sound – to help individuals
with dementia remember events, people and places from their
past lives. As part of the therapy, care partners may use objects
in various activities to help individuals with recall of memories.
• Validation Psychotherapy: Validation therapy is a type of
interactive cognitive therapy developed by Naomi Feil for use in
older adults with cognitive disorders and Dementia. It is a way
to approach older adults with empathy and understanding.

CONTD….
• Sensory Integration: It is an attempt to treat sensory processing
disorder and related situations. Sensory stimulation can
encompasses a variety of dementia friendly activities from
taking a walk outside and enjoying the feeling of the sun and
scent of flowers, to cooking or even looking through old
photographs.
• Stimulated Presence therapy: Stimulated Presence therapy is a
type of treatment which has been used mainly in nursing homes.
It is a relatively new intervention, which has been reported to
reduce levels of anxiety and challenging behavior among people
with dementia. The intervention consists of playing a tape of
their carer’s voice to a person with dementia over a personal
stereo.

CONTD….
• Cognition-Oriented Approach:
- These techniques include reality orientation and skills training.
- The aim of these treatments is to redress cognitive deficits.
• Stimulation-Oriented Approach:
- These treatments include activities or recreational therapies (e.g.
crafts, games and pets) and art therapies (e.g. music, dance and
art).
- They provide stimulation and enrichment and thus mobilize the
patient’s available cognitive resources.

COMPLEMENTARY
THERAPIES
• Aromatherapy: Particularly with lemon balm and lavender (for
relaxation)
• Massage therapy for agitation.
• Bright Light Therapy: For sleep disturbance or low mood.

PAIN MANAGEMENT
• Although persistent pain in the person with Dementia is difficult
to communicate diagnose and treat, failure to address persistent
pain has profound functional, psychosocial and quality of life
implications for tis vulnerable group.

SYMPTOMATIC MANAGEMENT
• Environmental manipulation and focus on coping skills to
reduce stress in day-to-day activities.
• Treatment of medical complications, if any.
• Care of food and hygiene
• Supportive care for the patient and family/carers.
• Short-term hospitalization may be needed for emergent
symptoms whilst a longer term hospitalization or respite
placement may be necessary in later stages

NURSING MANAGEMENT
Nursing Assessment:
• Assess the key areas in history, Mental Status Examination
and Mini Mental Status Examinations and other
examinations to get probable symptoms and defect.
• Assessment domains include:
- Cognitive assessment
- Functional assessment
- Behavioral assessment
- Physical assessment

CONTD….
• Cognitive Assessment:
- Orientation
- Memory
- Attention
- Thinking
- Language
- Executive function
• Functional Assessment:
- Functional activities of daily living

CONTD….
• Behavioral Assessment:
- Agitation
- Aggression
- Anxiety
- Disinhibition
- Delusions
- Depression
- Hallucinations
• Physical Assessment:
- Comprehensive physical Examination

NURSING DIAGNOSIS
• Disturbed thought process related to impaired cognitive abilities as
evidenced by disorientation, memory loss.
• Impaired verbal communication related to impaired abstract
thinking as evidenced by aphasia, apraxia and dysphasia.
• Impaired Physical mobility related to perceptual impairment and
pain as evidenced by immobility and decreased fine and gross motor
skills.
• Self-care deficit related to cognitive impairment as evidenced by
inability to perform activities of daily living.
• Risk for injury related to inability to identify hazards in the
environment as evidenced by confusion, disorientation and
Sundowning.
• Social isolation related to confusion, memory loss and agitation as
evidenced by feelings of rejection and isolation from others.

NURSING INTERVENTION
• Daily routine:
- Maintaining a daily routine includes drawing up a fixed
timetable for the patient for waking up in the morning, toilet,
exercise and meals. This gives the patient a sense of security.
- Patients often deteriorate after dark, a phenomenon known as
'Sundowning'. Additional care must be taken during the evening
and at night. Orient the patient to reality in order to decrease
confusion, clock with large face said in orientation to time.
- Use calendar with large writing and a separate page for each day.
- Provide newspapers which stimulate interest in current events.
- Orientation of place, person and time should be given before
approaching the patient.

CONTD….
• Nutrition and Body weight:
- Patient should be provided a well-balanced diet, rich in
protein, high in fiber, with adequate amount of calories.
- Allow plenty off time for meals. Tell the patient which meal
it is and what is there to eat; food served should be neither
too hot nor too cold.
- Many patients have sugar craving. Care should be taken that
such patients do not gain weight. The diet should take into
account other medical illnesses which require diet
modification, such as diabetes or high blood pressure.
- Semisolid diet is the safest while liquids are the most
dangerous as these can be easily aspirated into the lungs.

CONTD….
• Personal Hygiene:
- Particular care should be taken about the patient's personal
hygiene including brushing of teeth, bathing, keeping the
skin clean and dry, particularly in areas prone to
perspiration, such as the armpits and groin.
- Caustic substances such as spirit or antiseptic solutions
should not be used routinely on the skin.
- Remember to check finger and toe nails regularly, cut them
if the person cannot do it by himself.
- People with dementia may have problem with the lock on
the bathroom door; if this happens it is advisable to remove
the lock.
- Compliment the patient when he/ she looks good.

CONTD….
• Toilet Habits and Incontinence:
- Toilet habits should be established as soon as possible and
maintained as a rigid routine.
- This includes conditioned behavior such as going for bowel
movement immediately after a cup of tea.
- The patient should be taken to urinate at fixed interval,
depending on the season and amount of fluid intake.
- Prostate trouble common in elderly men leads to discomfort
as it causes urgency and frequency of urination particularly
in winters. A doctor should check this.
- Incontinence is very distressing to the patient and family.
Once incontinence sets in, the undergarments, pants of the
patient and the house in general start reeking of foul smell.

CONTD….
- Toilet habits established in healthy years must be maintained
as long as possible by gently persuading the patient to go to
the toilet and use it.
- When the first sign of incontinence appears doctor should
check for an underlying cause if any, such as urinary
infection or urinary tract damage.
- Constipation is a frequent cause of discomfort to the patient.
The quantity of faeces passed each morning should be
checked to ensure that the patient is not constipated.
Constipation can be avoided by adding fiber supplements
and roughage to the diet on a daily basis.

CONTD….
• Accidents:
- Great care should be taken to avoid accidents caused by
tripping over furniture, falling down the stairs or slipping in the
bathroom.
- The reasons for falling include loose and poorly fitting
footwear and wrinkled carpets. Ideally, patients should be made
to wear soft slip-on shoes with straps which fit securely. Any
floor covering must be firmly secured.
- Older people have been driving for years and in modern cities
many people are dependent on their personal cars for
transportation. Once early signs of the disease appear, patients
should be gently persuaded to stop driving as this can pose a
hazard to them and others. Make sure that lights are bright
enough.
- Keep matches, bleach, and paints out of reach. Do not allow the
patient to take medication alone.

CONTD….
• Fluid Management:
- The patients require as much fluid as normal people and this
depends on the season.
- Ideally, sufficient fluid should be given during the day and
only the minimum essential amount of fluid (some water
with dinner) after 6pm. The last cup of tea should be given
around 5 pm. After that no beverages including tea, coffee,
cocoa or any other caffeine containing drinks should be
given, as all these promote urination.
- Proper fluid management will reduce bed-wetting and also
reduce the number of times the patient will need to get up
during the night.

CONTD….
• Moods and Emotions:
- Some patients of Alzheimer's disease have abrupt change in their
moods and emotions. These changes can be unpredictable.
- Mood changes are best controlled by keeping a calm
environment with fixed daily routine. The patients should not be
questioned repeatedly or given too many choices, such as what
they want to eat or what they want to wear.
- Mood changes are also amenable to distraction, particularly if
topics related to the past are discussed or favorite pieces of
music played. For example, if music that reminds the patients of
their childhood is played, the pleasant associations put them in a
nostalgic mood.
- If patient behavior and emotions are distressing to the family
members, the doctor may prescribe some medications to calm
the patient.

CONTD….
• Wandering:
- Patients of Alzheimer's disease often lose their geographic
orientation and can get lost even in familiar surroundings.
- They may be found wandering aimlessly either in the
neighborhood or far away.
- It is advisable to have some identification bracelet or card
always in their possession.
- The doors of the house should be securely locked so that the
patients cannot leave unnoticed.
- The patient should always be accompanied while going for
walks or for simple chores outside the house.

CONTD….
• Disturbed sleep:
- Sleep disturbances are extremely distressing to the family. If
the patient is restless at night or wanders and talks at night,
the entire family is disturbed.
- Sleep patterns must be maintained.
- Napping during the day should be avoided.
- Sleeping pills are best avoided as their effect is temporary
and frequently unpredictable in patients of Alzheimer's
disease.
- Causes of discomfort at night, such as pain, uncomfortable
temperature or prostate trouble, should be checked.

CONTD….
• Interpersonal Relationship:
- Verbal communication should be clear and unhurried.
Questions that require 'yes', or 'no' answers are best.
- Reinforce socially acceptable skills.
- Give necessary information repeatedly.
- Focus on things the person does well rather than on mistakes
or failures.
- Try to make sure that each day has some thing of interest for
the patient- it might be going for a walk, listening to music;
talk about the day's activities.
- Try to involve patient with old friends for a chat,
reminiscing about the past.

CONTD….
• Family members should be aware of early warning signs
which may suggest that one of the older members may be on
the verge of developing Alzheimer's disease.
• Early diagnosis and early intervention can be beneficial both
to the patient and the family.
• As the disease progresses, the family remains the main pillar
of support for the patient.
• Alzheimer's associations around the world provide practical
and emotional help and information to families, health care
professionals and the community. Alzheimer's and Related
Disorders Society of India (ARDSI) started in 1992, a
national organization dedicated to dementia care, support
and research.

DELIRIUM
• Other terms used to describe delirium:
- Acute organic brain syndrome
- Acute Confusional state
- Acute brain failure
- Acute organic psychosis
- Intensive care unit psychosis
- Acute brain failure
- Central nervous system toxicity

DEFINITION
• Delirium is an Acute, transient, usually reversible,
fluctuating disturbances in attention, cognition and
consciousness level
OR
• Delirium is an acute organic mental disorder characterized
by impairment of consciousness, disorientation and
disturbance in perception and restlessness.

EPIDEMIOLOGY
• It is a common problem with a prevalence of 0.4% in general
population.
• 1.1% in general population aged more than 55 years.
• 9-30% in general hospital admissions.
• 5-55% in elderly general hospital admission.

TYPES OF DELIRIUM
TYPES OF DELIRIUM
HYPERACTIVE OR
AGITATED
DELIRIUM
HYPOACTIVE OR
QUIET DELIRIUM
MIXED TYPE

CONTD….
1. HYPERACTIVE OR AGITATED DELIRIUM:
• It is probably the most easily recognized type, this may include
restlessness (e.g. Pacing), agitation, rapid mood changes or
hallucinations, and refusal to cooperate and care.
2. HYPOACTIVE OR QUIET DELIRIUM:
• This may include inactivity or reduced motor activity,
sluggishness, abnormal drowsiness, or seeming to be in a daze. It
presents as a decreased sensorium or increased sedation.
3. MIXED DELIRIUM/MIXED TYPE:
• This includes both hyperactive and hypoactive signs and
symptoms. Alertness between the agitated and sedated forms.

The DSM-IV-TR (APA, 2000) differentiates between the disorders
of delirium by their etiology, although they share a common
symptom presentation. Categories of delirium include:
1. Delirium due to a general medical condition
2. Substance-induced delirium
3. Substance-intoxication delirium
4. Substance-withdrawal delirium
5. Delirium due to multiple aetiologies.

CONTD….
1. Delirium due to General Medical conditions:
• In this type of delirium, evidence must exist (from history, physical
examination, or laboratory findings) to show that the symptoms of
delirium are a direct result of the physiological consequences of a
general medical condition (APA, 2000).
• Such conditions include:
- Systemic infections
- Metabolic disorders (e.g., hypoxia, hypercarbia, and hypoglycemia)
- Fluid or electrolyte imbalances
- Hepatic or renal disease
- Thiamine deficiency
- Postoperative states
- Hypertensive encephalopathy
- Postictal states, and sequelae of head trauma (APA, 2000).

CONTD….
2. Substance-Induced Delirium:
• This disorder is characterized by the symptoms of delirium that
are attributed to medication side effects or exposure to a toxin.
The DSM-IV-TR (APA, 2000) lists the following examples of
medications that have been reported to result in substance-
induced delirium:
- Anesthetics
- Analgesics
- Antiasthmatic agents
- Anticonvulsants
- Antihistamines
- Antihypertensive and cardiovascular medications

CONTD….
• Antimicrobials
• Antiparkinsonian drugs
• Corticosteroids
• Gastrointestinal medications
• Histamine H2-receptor antagonists (e.g., cimetidine),
• Immunosuppressive agents
• Lithium
• Muscle relaxants, and psychotropic medications with
anticholinergic side effects.
• Toxins reported to cause delirium include organophosphate
(anticholinesterase) insecticides
• Carbon monoxide, and volatile substances such as fuel or
organic solvents.

CONTD….
3. Substance-Intoxication Delirium:
• With this disorder, the symptoms of delirium may arise within
minutes to hours after taking relatively high doses of certain
drugs such as cannabis, cocaine, and hallucinogens.
• It may take longer periods of sustained intoxication to produce
delirium symptoms with alcohol, anxiolytics, or narcotics
(APA, 2000).

CONTD….
4. Substance Withdrawal Delirium:
• Withdrawal delirium symptoms develop after reduction or
termination of sustained, usually high-dose use of certain
substances, such as alcohol, sedatives, hypnotics, or anxiolytics
(APA, 2000).
• The duration of the delirium is directly related to the half-life
of the substance involved and may last from a few hours to 2 to
4 weeks.

CONTD….
5. Delirium Due to Multiple Etiologies:
• This diagnosis is used when the symptoms of delirium are
brought on by more than one cause.
• For example, the delirium may be related to more than one
general medical condition or it may be a result of the combined
effects of a general medical condition and substance use (APA,
2000).

ETIOLOGICAL FACTORS
IMPLICATED IN THE
DEVELOPMENT OF DELIRIUM
- METABOLIC CAUSES:
i. Hypoxia, Carbon dioxide narcosis
ii. Hypoglycaemia
iii. Hepatic encephalopathy, Uremic encephalopathy
iv. Cardiac failure, Cardiac arrhythmias, Cardiac arrest
v. Water and electrolyte imbalance (Water, Na+, K+, Mg++,
Ca++)
vi. Metabolic acidosis or alkalosis vii. Fever, Anaemia,
Hypovolemic shock
vii. Carcinoid syndrome, Porphyria

CONTD….
- ENDOCRINE CAUSES:
i. Hypo- and Hyperpituitarism
ii. Hypo- and Hyperthyroidism
iii. Hypo- and Hyperparathyroidism
iv. Hypo- and Hyperadrenalism

CONTD….
- DRUGS (BOTH INGESTION AND WITHDRAWAL CAN
CAUSE DELIRIUM) AND POISONS :
i. Digitalis, Quinidine, Antihypertensive
ii. Alcohol, Sedatives, Hypnotics (especially barbiturates)
iii. Tricyclic antidepressants, Antipsychotics, Anticholinergics,
Disulfiram
iv. Anticonvulsants, L-dopa, Opiates
v. Salicylates, Steroids, Penicillin, Insulin.
vi. Methyl alcohol, heavy metals, biocides.

CONTD….
- NUTRITIONAL DEFICIENCIES:
i. Thiamine
ii. Niacin
iii. Pyridoxine
iv. Folic Acid
v. B12
- SYSTEMIC INFECTIONS:
Acute and Chronic (e.g. Septicemia, Pneumonia and
endocarditis)

CONTD….
- INTRACRANIAL CAUSES:
• Epilepsy
• Head Injury, subarachnoid, haemorrhage, subdural hematoma
• Intracranial infections, e.g. meningitis, encephalitis cerebral
malaria.
• Stroke
• Hypertensive encephalopathy
• Focal lesions, e.g. right parietal lesions

CONTD….
- MISCELLANEOUS:
• Postoperative states
• Sleep deprivation
• Heat
• Electricity and radiation.

MNEMONIC FOR ETIOLOGY
A useful mnemonic for remembering possible cause of delirium is “I
WATCH DEATH”
• Infections
• Withdrawal drug or alcohol
• Acute metabolic conditions
• Trauma
• CNS Pathology
• Hypoxia
• Deficiencies, vitamins
• Endocrinopathies
• Acute vascular conditions
• Toxins or drugs
• Heavy metals poisoning

CLINICAL FEATURES
• Level of consciousness: is often affected, with a disturbance in
the sleep–wake cycle. The state of awareness may range from that
of hypervigilance (heightened awareness to environmental
stimuli) to stupor or semicoma.
• Sleep: Sleep may fluctuate between hypersomnolence (excessive
sleepiness) and insomnia. Vivid dreams and nightmares are
common.
• Psychomotor activity: It may fluctuate between agitated,
purposeless movements (e.g., restlessness, hyperactivity, striking
out at nonexistent objects) and a vegetative state resembling
catatonic stupor. Various forms of tremor are frequently present.

CONTD….
• Emotional instability: It may be manifested by fear, anxiety,
depression, irritability, anger, euphoria, or apathy. These various
emotions may be evidenced by crying, calls for help, cursing,
muttering, moaning, acts of self destruction, fearful attempts to
flee, or attacks on others who are falsely viewed as threatening.
Autonomic manifestations, such as tachycardia, sweating, flushed
face, dilated pupils, and elevated blood pressure, are common
• Perception: Visual perception is the modality most often affected.
Illusions and misinterpretations are frequent.

CONTD….
• Reduced Awareness of the environment: This may result in:
- An ability to stay focused on a topic or to switch topics
- Getting stuck on an idea rather than responding to questions or
conversations.
- Being easily distracted by unimportant things
- Being withdrawn, with little or no activity or little response to the
environment.

CONTD….
• Poor thinking skills (Cognitive impairment): This may result in:
- Orientation: In obvious cases, orientation in person, time, and
place will be disturbed.
- Attention and Concentration: Both are impaired.
- Memory disturbances: These are seen, particularly recent events
and impaired registration (e.g. digit span), short-term recall (e.g.
Name and address), and long-term recall (e.g. current news
items).
- Speech: The patient may mumble and be incoherent. Difficulty
speaking or recalling words. Rambling or nonsense speech.
Trouble understanding speech. Difficulty reading or writing.
- Insight: Insight is usually impaired.

CONTD….
• The symptoms of delirium usually begin quite abruptly (e.g.
following a head injury or seizure)
• At other times, they may be preceded by several hours or days of
prodromal symptoms (e.g. Restlessness, difficulty thinking
clearly, insomnia or hyper-somnolence, and nightmares)
• The duration of delirium is usually brief (e.g. 1 week; rarely more
than 1 month) and, upon recovery from the underlying
determinant, symptoms usually diminish over a 3- to 7-day
period, but in some instances may take as long as 2 weeks.
(Sadock and Sadock, 2007)
• Delirium may transition into a more permanent cognitive disorder
(e.g., dementia) and also is associated with a high mortality rate
(Bourgeois, Seaman, & Servis,2008)

DIAGNOSTIC CRITERIA
ACCORDING TO DSM-5
A. A disturbance in attention (i.e. Reduced ability to sustain,
and shift attention) and awareness (reduced orientation to
environment).
B. The disturbance develops over a short period of time
(Usually hours to few days), represents a change from
baseline attention and awareness, and tends to fluctuate in
severity during the course of a day.
C. An additional disturbance in cognition (e.g. memory
deficit, disorientation, language , visuospatial ability or
perception)

CONTD….
D. The disturbance in criteria A and C are not explained by
another pre-existing, established, or evolving
neurocognitive disorder and do not occur in the context of
a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination,
or laboratory findings that the disturbance is consequence
of another medical condition, substance intoxication or
withdrawal (i.e. due to drug abuse or due to a
medication), or exposure to a toxin, or is due to multiples
etiologies.

DIAGNOSIS
• Physical examination: Physical examination reveals the
cause of delirium.
• Cognitive Testing:
- Mini Mental Status Examination
- Mental Status Examination
- Cognitive abilities screening instrument (CASI)

CONTD….
• Laboratory Tests:
- Routine blood tests
- Vitamin B12
- Folic Acid
- Thyroid Stimulating Hormone (TSH)

CONTD….
• Confusion Assessment Method (CAM):
- It is a standardized evidence-based tool that enable non-
psychiatrically trained clinicians to identify and recognize
delirium quickly and accurately in both clinical and research
setting.
• Imaging:
- CT Scan or Magnetic Resonance Imaging (MRI Scan)

MANAGEMENT
The management strategies include both non-pharmacologic
and Pharmacologic interventions. There are four key steps in
management of delirium.
Addressing the
underlying causes
Maintaining behavioral
control
Preventing
complications
Supporting functional
needs

CONTD….
MANAGEMENT OF
DELIRIUM
Non-
Pharmacologic
Interventions
Physical Environmental Cognitive Psychological
Pharmacologic
Intervention
Symptomatic
Management

PHARMACOLOGICAL
INTERVENTION
• 100 mg of B12 for thiamine deficiency
• Intravenous fluids for fluid and electrolyte imbalance.

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.

NON-PHARMACOLOGIC
INTERVENTION
• Physical:
- Provide adequate hydration and appropriate nourishment.
- Physical restraints can be used only when all pharmacologic
interventions have failed.
• Psychological:
- 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.

CONTD….
• Environmental:
- Provide 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.
- Sundowning can be lessened by leaving a radio on in the
patient’s room.
- Provide care during hallucination; adequate daytime
lightning and a night light should be provided.

CONTD….
• Cognitive:
- Reorientation is one of the most easily accomplished
cognitive interventions.
- Place a clock and a calendar in patient’s room.
- Reorient patient verbally to time and place several times in a
day.
- Repetition of word is recommended.

NURSING MANAGEMENT
Nursing Assessment:
• Patient history
• Personality and Behavioral changes
• Cognitive problems (attention span, thinking process,
problem solving)
• Language difficulties
• Orientation level
• Appropriateness of social behavior
• Evidence of disease of other organs (Presumed cause of
illness).

NURSING DIAGNOSIS
• Risk for trauma related to impairment in cognitive and psychomotor
functions as evidenced by clouding of consciousness.
• Disturbed thought process related to cerebral degeneration as
evidenced by disorientation, confusion, memory deficit.
• Self-care deficit related to confusion, disorientation as evidenced by
inability to perform activities of daily living.
• Social isolation related to confusion, memory loss as evidenced by
isolation from others.

NURSING INTERVENTION
• Providing Safe Environment:
- Restrict environmental stimuli, keep unit calm and well-
illuminated.
- There should always be somebody at the patient's bedside
reassuring and supporting
- As the patient is responding to a terrifying unrealistic world of
hallucinatory illusions and delusions, special precautions are
needed to protect him from himself and to protect others.

CONTD….
• Alleviating Patient’s fear and Anxiety:
- Remove any object in the room that seems to be a source of
misinterpreted perception
- As much as possible have the same person all the time by
the patient's bedside
- Keep the room well lighted especially at night.

CONTD….
• Meeting the Physical needs of Patients:
- Appropriate care should be provided after physical
assessment.
- Use appropriate nursing measures to reduce high fever, if
present.
- Maintain intake and output chart
- Mouth and skin should be taken care of.
- Monitor vital signs
- Observe the patient for any extreme drowsiness and sleep as
this may be an indication that the patient is slipping into a
coma.

CONTD….
• Facilitate Orientation:
- Repeatedly explain to the patient where he is and what date,
day and time it is.
- Introduce people with name even if the patient misidentifies
the people.
- Have a calendar in the room and tell him what day it is.
- When the acute stage is overtake the patient out and
introduce him to others.

PATIENT EDUCATION
• Educating families and patients regarding the etiology and
course of disease is an important role for physician.
• Educate the patient, family and primary care givers about future
risk factors.
• Families may worry that the patient has brain damage or a
permanent psychiatric illness. Providing reassurance that
delirium often in temporary and is 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 calm and structured environment.
Encourage them to furnish some familiar objects, such as photos
or favourite blanket, to help reorient the patient and make the
patient feel more secure.

DIFFERENCE BETWEEN
DELIRIUM AND DEMENTIA

INTRODUCTION
• Amnestic disorders are a group of disorders that involve loss of
memories, loss of ability to create new memories, or loss of
ability to learn new information.
• These disorders are characterized by problems with memory
function. There are a variety of symptoms associated with
amnestic disorders, as well as differences in the severity of
symptoms.
• The two main types of Amnestic disorders center on whatever or
not the cause of the memory problem is known.
• Organic Amnestic Syndrome is diagnosed when there is a known
physical cause of the memory problems.
• Unspecified Amnestic Syndrome is diagnosed when the exact
cause of the memory loss is not fully known.

AMNESIA
• Amnesia refers to loss of memories such as facts, information
and experiences. It is characterized by the inability to retain or
recall past experiences. The condition may be temporary or
permanent, depending on etiology.
• Some people with Amnesia have difficulty forming new
memories.
• People with Amnesia usually retain knowledge of their own
identity, as well as motor skills.

AMNESTIC DISORDERS
• Amnestic disorders are characterized by an inability to learn new
information (short-term memory deficit) despite normal
attention, and an inability to recall previously learned
information (long-term memory deficit).
• Events from the remote past often are recalled more easily than
recently occurring ones.
• The syndrome differs from dementia in that there is no
impairment in abstract thinking or judgment, no other
disturbances of higher cortical function, and no personality
change.

ONSET/ DURATION/ COURSE
• The onset of symptoms may be acute or insidious, depending on
the pathological process causing the amnestic disorder.
• Duration and course of the illness may be quite variable and are
also correlated with extent and severity of the course.

TYPES OF AMNESIA
TYPES
OF
DELIRIUM
RETROGRADE AMNESIA
ANTEROGRADE AMNESIA
TRANSIENT GLOBAL
AMNESIS
INFANTILE AMNESIA
PROFOUND AMNESIA

CONTD….
1. Retrograde Amnesia:
• It means people experience difficulty in recalling events that
happened or facts that they learned before the onset of Amnestic
disorder. This type of Amnesia is called Retrograde Amnesia.
• This type of Amnesia tends to affect recently formed memories
first. Diseases such as Dementia cause gradual Retrograde
Amnesia.

CONTD….
2. Anterograde Amnesia:
• The inability to learn new facts or retain new memories, which
is called Anterograde Amnesia.
• This effect can be temporary e.g. individual experience it during
a blackout caused by too much Alcohol.
• It can also be permanent, if the area of brain i.e. hippocampus is
damaged.
• Hippocampus plays an important role in forming memories.

CONTD….
3. Transient Global Amnesia (TGA):
• It is poorly understood condition. If anyone develop it, they will
experience confusion or agitation that comes and goes
repeatedly over the course of several hours.
• They may experience memory loss in the hours before the attack
and will probably have no lasting memory of the experiences,
• Scientists think that Transient Global Amnesia occurs as a result
of seizure- like activity or a brief blockage of the blood vessels
supplying to the brain .
• Differentiation is made on the basis of an abrupt onset and
patient’s severe distress (because of memory loss) in transient
global amnesia.
• It occurs more frequently in middle aged and older adults.

CONTD….
4. Infantile Amnesia:
• Most people can’t remember the First Three to Five years of
life.
• This common phenomenon is called Infantile or Childhood
Amnesia.
5. Profound Amnesia:
• It may result in disorientation to place and time, but rarely to
self. (APA, 2000)

Amnestic disorders share a common symptom presentation of
memory impairment but are differentiated in the DSM-IV-TR
(APA, 2000) according to etiology.
1. Amnestic disorder due to a general medical condition
2. Substance-induced persisting amnestic disorder
3. Dementia
4. Anoxia
5. Damage to Hippocampus

CONTD….
6. Head Injuries
7. Alcohol Use
8. Trauma or Stress
9. Electroconvulsive Therapy

CONTD….
1. Amnestic Disorder due to General Medical conditions:
• In this type of amnestic disorder, evidence must exist from the
history, physical examination, or laboratory findings to show
that the memory impairment is the direct physiological
consequence of a general medical condition (APA, 2000).
• The diagnosis is specified further by indicating whether the
symptoms are transient (present for no more than 1 month) or
chronic (present for more than 1 month).

CONTD….
• General medical conditions that may be associated with amnestic
disorder include:
- Head trauma
- Cerebrovascular disease
- Cerebral neoplastic disease
- Cerebral anoxia
- Herpes simplex encephalitis
- Poorly controlled insulin dependent diabetes, and
- Surgical intervention to the brain (Andreasen & Black, 2006;
APA, 2000).
• Transient amnestic syndromes can occur from cerebrovascular
disease, cardiac arrhythmias, migraine, thyroid disorders, and
epilepsy (Bourgeois et al., 2003).

CONTD….
2. Substance Induced Persisting Amnestic Disorder:
• In this disorder, evidence must exist from the history, physical
examination, or laboratory findings that the memory impairment
is related to the persisting effects of substance use (e.g., a drug
of abuse, a medication, or toxin exposure; APA, 2000).
• The term persisting is used to indicate that the symptoms exist
long after the effects of substance intoxication or withdrawal
have subsided.
• The DSM-IV-TR identifies the following substances with which
amnestic disorder can be associated:
- Alcohol
- Sedatives, hypnotics, and anxiolytics

CONTD….
- Medications
a. Anticonvulsants
b. Intrathecal methotrexate
- Toxins
a. Lead
b. Mercury
c. Carbon monoxide
d. Organophosphate insecticides
e. Industrial solvents
• The diagnosis is made according to the specific etiological substance
involved. For example, if the substance known to be the cause of the
amnestic disorder is alcohol, the diagnosis would be Alcohol-Induced
Persisting Amnestic Disorder.

CONTD….
3. Dementia:
• To lose old memories, widespread brain deterioration.
• This can be caused by Alzheimer’s Disease or other forms of
Dementia.

CONTD….
4. Anoxia:
• A depletion of oxygen level can also affect entire brain and lead
to memory loss. This condition is called Anoxia.
• If the anoxia isn’t severe enough to cause brain damage, the
memory loss can be temporary.

CONTD….
5. Damage to Hippocampus:
• Hippocampus is a part of the brain and limbic system which is
responsible for memory.
• Its activities include forming memories, organising memories,
retrieving them when needed,
• Its cells are most easily disrupted by Anoxia and other threats
such as toxins.
• When hippocampus is impaired, individual will have difficulty
in forming new memories.
• If hippocampus is damaged in both halves of brain, one can
develop complete Anterograde Amnesia.

CONTD….
6. Head Injuries:
• Traumatic Head Injury as well as stroke, tumors and infection
can also cause damage to the brain.
• This damage can include permanent memory problems.
• Concussions commonly disrupt memories of the hours, days or
weeks before and after the individual is injured.

CONTD….
7. Alcohol Use:
• Short term Alcohol use can cause blackout. This is a temporary
form of Anterograde Amnesia.
• Long-term alcoholism can cause Wernickes-Korsakoff
Syndrome.
• If individual develop this condition, will have difficulty in
forming new memories but may not aware of it.

CONTD….
8. Trauma or Stress:
• Severe trauma or stress can also cause dissociative Amnesia.
• With this condition individual’s mind rejects thoughts, feelings
or information that individual is too overwhelmed to handle.
• A specific type of dissociative Amnesia called Dissociative
fugue, can lead to unexpected travelling or wandering.
• It can also lead to amnesia around the circumstances of
travelling as well as forgetting other details of one’s life.

CONTD….
9. Electroconvulsive Therapy:
• Individual experience retrograde Amnesia for the weeks or
month before treatment.
• One could also experience anterograde Amnesia, usually
resolving with in 2 weeks of the treatment.

CLINICAL FEATURES
• A defect of recent memory (impaired learning of new material),
to a degree sufficient to interfere with daily living.
• A reduced ability to recall past experiences.
• No defect in immediate recall.
• Clear state consciousness
• No disturbance of attention
• Evidence of organic brain disease.

AMNESIA PREVENTION
The following healthy habits can lower the risk of blackout, head
injuries, dementia, stroke and other potential cause of memory loss.
- Avoid heavy use of Alcohol or Drugs.
- Use protective headgear when you are playing sports that put you
at high risk of concussions.
- Stay mentally active throughout life. For instance: take classes,
explore new places, read new books, and play mentally
challenging games.
- Stay physically active throughout life.
- Eat a heart healthy diet, including fruits, vegetables, whole grains
and low fat protein.
- Stay Hydrated.

TREATMENT
To treat Amnesia, doctor will focus on the underlying cause of
condition:
• Chemically induced Amnesia: For example From Alcohol. It can
be resolved through detoxification. Once the drug is out of the
system, memory problems will probably subside.
• Amnesia from mild Head trauma: It usually resolves without
treating overtime. Amnesia from severe head injury may not
recede. However, improvements usually occur within 6 to 9
months.

CONTD….
• Amnesia from Dementia: It is often incurable. However, doctor
may prescribe medication to support learning and memory.
- Therapist can also teach how to use memory aids and techniques
for organizing information to make it easier to retrieve.
• Treatment of Underlying Medical condition: Treating thyroid
function, liver and kidney disease, stroke and head injury.
• Treatment of concomitant psychiatric illness: Treating
depression, anxiety, bipolar disorder and Schizophrenia.

CONTD….
• Treating Alcoholism: Preventing Alcohol and illicit drug abuse.
• Cognitive Therapy: Use speech or language therapist to help
patients with mild and Moderate memory Loss.
• Occupational Therapy: If anyone have persistent memory loss,
doctor may recommend occupational therapy. An occupational
therapist can help individual to learn new information, or to
teach strategies to organize information.

NURSING MANAGEMENT
• Prevention of fall: Good lightning and avoidance of
confusion help to prevent falls.
• Maintain Safety: Keep dangerous material locked up and
make sure that the person cannot lock themselves in a room.
• Prevent lost wandering: Make sure patient carry
identification card with their name and address or contact
number.
• Prevent burn: Install hot water shut-down and thermostats
with safety taps.

CONTD….
• Prevent common accidents: Install smoke alarm as patient may
forget to switch off stove.
• Medication: Make sure that patient take medications regularly
and set pill reminders.

INTRODUCTION
• The organic personality disorder is characterised by a significant
alteration of the pre morbid personality caused by an underlying
organic cause without major disturbance of consciousness,
orientation, memory or perception.
• A variety of neurological and other general medical conditions,
including Central Nervous System (CNS) neoplasms,
cerebrovascular disease, Huntington’s disease, epilepsy,
endocrine conditions, and autoimmune conditions may cause
personality changes.
• On the basis of the predominant symptom presentation Duffy
and Campbell (2001) identify three distinct prefrontal syndrome.

CONTD….
ORGANIC
PERSONALITY
DISORDERS
Dysexecutive Type Disinhibited Type Apathetic Type

CONTD….
1. Dysexecutive Type: Diminished attention, planning, Insight,
cognitive dysfunctioning, Motor functioning and diminished
self-care.
2. Disinhibited Type: Diminished social insight, distractibility
and emotional lability.
3. Apathetic Type: Diminished spontaneity, verbal output and
motor behavior, urinary incontinence, lower extremity
weakness and sensory loss and increased response latency.

ETIOLOGY
• Temporal lobe epilepsy (complex partial seizures) which can
be associated with temporal lobe (personality) syndrome
• Concussion (postconcussional syndrome)
• Encephalitis (post encephalitis syndrome)
• Multiple sclerosis (early)
• Cerebral neoplasms, especially in frontal lobe (frontal lobe
syndromes) and parietal lobe
• Cerebrovascular disease
• Psychoactive drugs (rarely).

MANAGEMENT
• Treatment of the underlying cause, if treatable.
• Symptomatic treatment, with lithium or carbamazepine for
aggressive behaviour and impulse dyscontrol, and/or
antipsychotics (occasionally) for violent behaviour may be
needed.

INTRODUCTION
• Abnormalities of mood and affect are among the most common
neuropsychiatric disturbances.
• According to ICD-10, presence of prominent and persistent
mood disturbance caused by an underlying organic cause is
required for the diagnosis of organic mood disorder, in addition
to the general guidelines for the diagnosis of other organic
mental disorders, described earlier.
• The mood disturbance can be a major depressive episode, a
manic episode, or a mixed affective episode.
• It has been observed that depression is under recognized and
undertreated in patients with neurological conditions.
• The severity may vary from mild to severe.

CONTD….
• Assessment of core psychological features of depression,
including sadness, feelings of guilt, worthlessness, hopelessness
and helplessness is critical in recognizing depression in patients
with neurological disorders.
• Organic mania is often difficult to treat.

ETIOLOGY
1. Drugs:
• Mania:
- INH
- Levodopa
- Bromide
- LSD
- Corticosteroids (hypomania)
- Hallucinogens
- Tricyclic antidepressants
- Cocaine,

CONTD….
- Amphetamines
- Bromocriptine
- Corticosteroids,
- Antipsychotics (particularly typical antipsychotics)
Anticancer chemo therapy
- Oral contraceptives.
- Any drug a depressed person is taking should be considered a
potential factor in the causation of depressive episode.

CONTD….
2. Endocrine disorders:
• Mania:
- Hyperthyroidism
• Depression:
- Hypothyroidism
- Cushing’s syndrome
- Addison’s disease
- Hyper- and hypoparathyroidism

CONTD….
3. CNS disorders:
- Parkinsonism
- Huntington’s chorea
- PSP (progressive Supranuclear palsy; depression more likely)
- CVAs (cerebrovascular accidents; left-sided anterior lesions and
right sided posterior lesions cause depression in stroke)
- Cerebral tumours
- Epilepsy (complex partial seizures)
- Neurosyphilis (GPI)
- Head injury (mania more likely)
- Multiple sclerosis.

CONTD….
4. Post-viral illnesses:
• Influenza
• Infectious mononucleosis
• Viral pneumonia
• Infectious hepatitis
5. Deficiencies:
• Pellagra
• Deficiency of thiamine
• Niacin
• Folate
• B12.

CONTD….
6. Others:
• Carcinoma pancreas (depression),
• SLE
• pernicious anaemia
• temporal arteritis (depression)
• carcinoid syndrome (mania).

MANAGEMENT
• Management of the underlying organic cause, if treatable.
• Symptomatic management, if the episodes are severe. For
example, for a manic episode, low dose antipsychotic
medication (such as risperidone, haloperidol, olanzapine)
and/or a mood stabilizer (such as valproate); and for a
depressive episode, low dose antidepressants (such as
sertraline or mirtazapine).
• Antipsychotics are not recommended in patients who have
suffered from stroke and/or dementia as the risk of mortality
is higher. Pathological laughter and crying (associated with
multiple sclerosis or stroke) can similarly respond to small
dose SSRIs or small dose amitriptyline.

INTRODUCTION
• It is a disorder of persistent or recurrent hallucinations; usually
visual or auditory; that occur in clear consciousness; in the
absence of significant intellectual decline, predominant
disturbance of mood and predominance of delusions.
• Hallucinations have been reported in various neurological and
systemic medical disorders.
• According to ICD-10, presence of persistent or recurrent
hallucinations due to an underlying organic cause is required for
the diagnosis of organic hallucinosis.
• These hallucinations can range from very simple and unformed,
to very complex and well-organised. Usually the patients realize
that the hallucinations are not real but some times there may be
a delusional elaboration of hallucinations.

ETIOLOGY
1. Drugs:
- Hallucinogens (LSD, psilocybin, mescaline)
- Cocaine
- Cannabis
- Phencyclidine (PCP)
- Levodopa
- Bromocriptine
- Amantadine
- Methylphenidate
- Imipramine
- Anticholinergics

CONTD….
2. Alcohol:
- In alcoholic hallucinosis, auditory hallucinations are usually
more common
3. Sensory deprivation
4. ‘Release’ hallucinations due to sensory pathway disease, e.g.
bilateral cataracts, otosclerosis, optic neuritis.
5. Migraine

CONTD….
6. Epilepsy:
- Complex partial seizures
7. Intracranial space occupying lesions
8. Temporal arteritis
9. Brain stem lesions (peduncular hallucinosis).

MANAGEMENT
• Treatment of the underlying cause, if treatable.
• Symptomatic treatment with a low dose of an antipsychotic
medication (such as Haloperidol, Risperidone and
Olanzapine) may be needed.

INTRODUCTION
• Anxiety has been associated with neurological disorders like
stroke, Parkinson’s Disease, Multiple Sclerosis, Epilepsy and
Post-Traumatic encephalopathy.
• Medications associated with anxiety include levodopa, tricyclic
antidepressants, bupropion, fluoxetine, isoniazid and Thyroid
hormones.
• Post-stroke anxiety is more likely to occur with left anterior
cortical lesions.
• According to ICD-10, presence of prominent and persistent
generalized anxiety or panic caused by an underlying cause is
required for diagnosis of organic anxiety disorder.
• It is important to rule out any major disturbance of
consciousness, orientation, memory, personality, thought,
perception, or mood.

ETIOLOGY
1. Drugs and toxins:
- Cocaine
- Caffeine
- Amphetamines and other sympathomimetic
- Alcohol and drug withdrawal
- Heavy metals
- Penicillin.

CONTD….
2. Endocrine disorders:
- Thyroid, pituitary
- Parathyroid, or adrenal dysfunction
- Pheochromocytoma
- Fasting hypoglycaemia
- Carcinoid syndrome.

CONTD….
3. Systemic diseases:
- Cardiac arrhythmias
- Mitral valve prolapse syndrome
- Chronic obstructive pulmonary disease
- Coronary artery disease
- Pulmonary embolism
- Anaemia
- Fever
- Deficiency diseases.

CONTD….
4. CNS diseases:
- Cerebral tumours
- Epilepsy (especially complex partial seizures of temporal lobe
origin)
- Cerebrovascular disease
- Postconcussional syndrome.

MANAGEMENT
• Treatment of the underlying organic cause, if treatable.
• Symptomatic treatment with benzodiazepines, beta-blockers
(such as propranolol), cognitive behaviour therapy, and
relaxation techniques may be needed.

INTRODUCTION
• The Post-Concussion Syndrome (PCS) refers to the emergence
and variable persistence of a group of symptoms following head
injury, particularly mild head injury.
• Most descriptions include somatic symptoms (headache,
dizziness, fatigability, nausea, vomiting, drowsiness, blurred
vision, diplopia, insomnia, poor hearing, hypersensitivity to
noise and appetite changes) accompanied by psychological
symptoms, both cognitive (poor memory and concentration) and
affective (reduced tolerance for frustration, irritability,
emotional lability, depression and anxiety),

Organic Disorders

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