Organic Brain Syndrome

Daniel Tan

Norshazrin

Nur Nazilahani

Delirium

• Acute onset of fluctuating cognitive impairment and a disturbance of consciousness with reduced ability to attend.

• Hallmark/ most important feature: – impairment of consciousness, – Occur along with global impairment of cognitive

function

• Psychiatric symptoms: mood, perception, behaviour abnormalities

• Neuro symptoms: tremor, asterixis, nystagmus, incoordination, urinary incontinence.

Epidemiology

• 1.1% for gen pop. 55 y.o or more.

• 10-30% of hospitalised medical patients

• 30% of patients in surgical ICU

• 40-50% of patients in hip fracture surgery

• 20% of burn patients

• 30-40% of hospitalised AIDS patients

• 80% of terminally ill patients

Risk factors

• Extreme of age • Male gender • Hospitalisation • Nursing home residents • Preexisting brain damage (dementia, CVA, tumor) • Hx of delirium • Alcohol dependence • Diabetes • Cancer • Sensory impairment (eg: blindness) • Malnutrition

Etiology

Neuro causes

• Epilepsy

• Infections (Encephalitis)

• SOL (tumor)

• Raised ICP

• Trauma

Systemic causes

• Cardiac failure

• Respiratory failure

• Liver failure

• Renal failure

• Hypoglycemia

• Systemic infection

Drug/toxin intoxication/withdrawal

• Cocaine

• Amphetamine

• Hallucinogen

• Cannabis

• Opioids

• Phencyclidine (PCP)

• Sedative, anxiolytic, hypnotic

• Alcohol

Diagnosis (DSM-IV-TR)

• Disturbance of consciousness (reduced clarity of awareness of environment) with reduced ability to focus, sustain or shift attention

• Change in cognition (orientation, memory, language) or development of perceptual disturbances

• Acute onset (hours-days), fluctuate during course of the day

• Evidence from Hx, PE, lab Ix that disturbance is due to: – General medical condition

– Substance intoxication/ withdrawal

– More than one etiologies

Clinical features

• Altered consciousness • Altered attention

– Reduced ability to focus, sustain, shift attention

• Cognitive impairment – Disorientation (time, place, person) – Decreased memory

• Acute onset (hours-days) • Brief duration (days-weeks) • Marked unpredictable fluctuations, esp

evening/night (sundowning)

Core features

• Behavior – Overactive – Underactive

• Thinking – Slow, confused, tangentiality, incoherent – Delusions

• Mood – Anxious, irritable, perplexed – Depressed – Labile

• Perception – Visual hallucination – Illusions – Misinterpretation

• Memory – Impaired recent memory

• Insight – Impaired

Neuro symptoms - Autonomic

hyperactivity - Myoclonic

jerking - Dysarthria

PE and Investigations

• MSE, neuro examination – To document patient’s cognitive impairment and provide baseline for

monitor clinical course.

• Blood Ix (indicated by clinical situation) – FBC, ESR, C&S (infection) – Urea, creatinine, electrolytes (renal function) – Liver function test – Thyroid function test – Arterial blood gas

• Others – Urinalysis, C&S – ECG – Head CT/MRI (SOL, CVA) – EEG (generalised slowing of activity)

Differential diagnosis

• Dementia – Insidious onset, relatively consistent symptoms, – No decreased consciousness

• Schizophrenia – Hallucinations and delusions more constant – No change in consciousness and orientation

• Depression – Hypoactive symptoms of delirium quite similar to

depression. EEG can differentiate

• Brief psychotic disorder • Schizophreniform disorder

Course and prognosis

• Sudden onset • Symptoms last as long as the causative factors are

present (usually <1 wk) • Removal of causative factors, symptoms recede

over 3-7 day period, up to 2 wks. • Older patient, longer delirium period= longer

time to resolve • Delirium is a/w high mortality rate in 1 yr. (due to

the serious nature of the medical conditions that lead to delirium)

Treatment

• Treat the underlying cause

• Provide physical, sensory, environmental support

– To prevent delirious patients from accidents

– To make sure patient is not sensory deprived/overstimulated by the environment

– Have family or relatives in the room

– Pictures, clock, calendar, regular orientation to time, place, person makes delirium patient comfortable

Pharmacotherapy

• 2 major symptoms of delirium require pharmacological treatment: psychosis, insomnia

• Psychosis: haloperidol, 2-6mg IM, change to oral as soon as patient is calm. – Total daily dose of haloperidol 5-40mg – Atypicals may be considered, but limited trials

• Insomnia: short/intermediate half life benzodiazepine (lorazepam 1-2mg ON)

• Consider opioids if patient is delirious due to severe pain. (analgesic & sedative effects)

Delirium vs Dementia

Delirium Dementia

Cognitive impairment with reduced consciousness

Cognitive impairment with clear consciousness

Acute onset Insidious onset

Short duration (days-weeks) Long duration (months-years)

Impaired orientation Impaired orientation

Recent memory impaired Recent and remote memory impaired

Psychosis common Psychosis less common

Symptoms fluctuate, sundowning Symptoms stable throughout the day

Usually reversible 15% reversible

Awareness reduced Awareness clear

EEG changes No EEG changes

Dementia

*Definition

Generalized decline of intellect, memory, and personality, without impairment of conciousness, leading to functional impairment.

*Clinical features

Cognition

• Poor memory

• Impaired attention

• Aphasia, agnosia, apraxia

• Disorientation

• ‘Personality change’

Behaviour

• Odd and disorganized

• Restless, wandering

• Self-neglect

• Disinhibition

• Social withdrawal

Mood

• Anxiety

• Depression

Thinking

• Slow, impoverished

• Delusions

Perception

• Illusions

• Hallucination

Insight

• Impaired

*Prevalence

• 5% in the age group 65 years and above for moderate and severe dementia

• found to increase exponentially with age so that the subgroup aged 65 years to 69 years is 1.5– 2%, 75 to 79 year is 5.5-6.5% and 85 to 89 years is 20-22%

•Dementia shortens life expectancy; with estimates of median survival of 5 to 9.3 years

*Differential Diagnosis

• Delirium

• Depression

• Schizophrenia

Causes

*Irreversible Causes

Primary Degenerative Disease

• Alzheimer disease

• Lewy body dementia

• Frontotemporal dementia

• Huntington’s disease

• Wilsons\’s disease

• Multiple sclerosis

• Motor neuron disease

Traumatic Head Injury

Infection: HIV, encephalitis

Vascular: multi-infarct dementia

Toxins: alcohol

Anoxia: cardiac arrest, carbon monoxide poisoning

Metabolic: hepatic encephalopathy, diabetes mellitus

*Potentially Reversible Causes

• Normal-pressure hyrocephalus

• Intracranial tumours

• Chronic subdural hematoma

Neurological

• Vitamin b12

• Folic acid

• Thiamine

Vitamin deficiencies

• Hypothyroidism

• Cushing’s

Endocrine

*Assessment

• History taking

• Full physical examination

• Cognitive testing

– Mini Mental State Examination (MMSE)

• Lab Investigation

• Imaging

– CT/ MRI Brain

A. The development of multiple cognitive deficits manifested by:- 1. Memory impairment (impaired ability to learn new information

or to recall previously learned information) 2. One (or more) of the following cognitive disturbances: a. aphasia (language disturbance) b. apraxia (impaired ability to carry out motor activities

despite intact motor function) c. agnosis (failure to recognise or identify objects despite

intact sensory function) d. disturbance in executive functioning (i.e. planning,

organising, sequencing, abstracting) B. The cognitive deficits in criteria A1 and A2 each cause significant

impairment in social and occupational functioning and represent a significant decline from a previous level of functional.

DSM IV Criteria for Dementia

CPG Management Dementia

*Management

Bio

• Pharmacological

• Acetylcholinesterase inhibitor; donepezil, rivastigmine, galantamine

• For Agitation; antipsychotic

• For depression; SSRI (citalopram, sertraline), NSRI (Venlafaxine), tricyclic (clomipramine)

Psycho

• Specific psychotherapies

• Behavior oriented approach

• Emotion oriented approach

• Cognition oriented approach

• Stimulation oriented approach

• Psychoeducation of patient family and carers

Social

• Promote and maintain independence with a written care plan

Alzheimer’s Disease

*Clinical Features

Forgetfulness Disorientation Mood variation

Poor sleep Social behaviour

decline Personality change

Parietal lobe dysfunction;

dysphasia, dyspraxia and agnosia

*Course

A the development of multiple cognitive deficits manifested by both memory impairment and at least one of the aphasia, apraxia, agnosia, or a disturbance in executive functioning

B the cognitive deficits cause significant impairment in social or occupational functioning and represent a significant decline from pevious level of functioning.

C The course is characterized by gradual onset and continuing cognitive decline

D the cognitive deficits are not due to any of the following: other central nervous system conditions that cause progressive deficits in memory and cognition; systemic conditions that are know to cause demntia: substance-induced condition

E The deficits do not occur exclusively during the course of a delirium F The disturbance is not better accounted for by another Axis 1

disorder.

DSM IV Criteria for Alzheimer’s type

Vascular Dementia

• Or known as multinfarct dementia

• Ischemic/ non-ischemic

• Large/ small vessels

• Patchy impairment of cognitive function

DSM IV Criteria for Vascular Dementia

A the development of multiple cognitive deficits manifested by both 1 memory impairment 2 one or more of the following cognitive distrubance: aphaisa,

apraxia, agnosia, disturbance in executive functioning B the cognitive deficits cause significant impairment in social or

occupational and represent a significant decline from previous level of functioning

C Focal neurological signs and symptoms or laboratory evidence indicative of cerebrovascular disease that are judged to be etiologically related to disturbance

D the deficits do not occur exclusively during the course of delirium E the course is characterized by sustained periods of clinical stability

punctuated by sudden significant cognitive and functional losses.

Amnesic disorder Organic mood disorder

Organic delusional disorder Organic personality disorder

Other cognitive disorders

Amnesic disorder

• A.k.a Amnestic disorder • Characterized by a prominent disorder of recent memory, in

absence of generalized intellectual impairment seen in dementia or impaired consciousness seen in delirium

• impairment in the ability to create new memories • Aetiologies: (1)amnestic disorder caused by a general medical condition (e.g. head trauma) (2)substance-induced persisting amnestic disorder (e.g. caused by carbon monoxide poisoning or chronic alcohol consumption) (3) amnestic disorder not otherwise specified for cases in which the aetiology is unclear Oxford Psychiatry, 3rd edition

DSM-IV-TR: requires the development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall previously learned information, and the memory disturbance must cause significant impairment in social or occupational functioning. Clinical features: • Recent memory severely impaired • Remote memory spared • Disorientation in time • Confabulation (fill in memory gaps with false information that they believe to

be true) • Other cognitive functions preserved Duration Transient –less than 1 month Chronic – beyond 1 month

Oxford Psychiatry, 3rd edition

Aetiology

• Hypoglycaemia • Systemic illness (e.g. Thiamine deficiency (Korsakoff's

syndrome)) • Hypoxia • Head trauma • Brain tumour • CVA • Seizures • Multiple sclerosis • Herpes simplex encephalitis • Transient global amnesia • ECT • Substance related (e.g. alcohol ,BDZ)

• No specific treatment.

• Course – depends on aetiology and treatment (particularly acute treatment)

• has a static course (little improvement over time, but also no progression of the disorder except acute amnesias & amnesia associated with head trauma)

• Amnesia due to disease that destroy brain tissue, such as stroke, tumour, and infection, are irreversible

Organic mood disorder • Direct causes of mood disturbance • Depression, mania, anxiety • E.g. multiple sclerosis, Cushing's disease Organic delusional disorder • Occur in brain pathology • Associated with temporal lobe epilepsy causing delusional

disorder resembling schizophrenia Organic personality disorder • Brain damage that cause personality change, if severe

enough may classified as personality disorder Oxford Psychiatry, 3rd edition

Thank you