Organic Mental Disorders

Organic mental disorders

• Disorders with known organic cause
• Organic mental disorders are behavioural or
psychological disorders associated with
transient or permanent brain dysfunction and
include only those mental and behavioural
disorders that are due to demonstratable
cerebral disease or disorder, either
primary(primary brain pathology) or secondary
(brain dysfunction due to systemic diseases)
 Categories
• Delirium
• Dementia
• Organic amnestic syndrome
• Other organic mental disorders
Delirium
 Introduction
Delirium is the most common organic
mental disorder seen in clinical practice.
Celsus in the first century AD used the
terms delirium and dementia.
Pineal and Esquuirrol described senile
dementia. Alois Alzheimer reported the
first case of progressive dementia in
1906.
 Other terms
• Other terms used include organic brain
syndrome, metabolic encephalopathy, toxic
psychosis, acute mental status change,
exogenous psychosis, sun downing.
 Delirium
(more often a problem in medical in-patients)

 Disturbance of consciousness
 i.e., reduced clarity of awareness of the
environment with reduced ability to focus,
sustain, or shift attention
 Change in cognition (memory, orientation,
language, perception)
 Development over a short period (hours to
days), tends to fluctuate
 The primary cause is often outside the brain
 Delirium
• Delirium is a mental state characterized by a
disturbance of cognition, which is manifested
by confusion, excitement, disorientation, and
a clouding of consciousness. Hallucinations
and illusions are common.
 Epidemiology

• The exact incidence and prevalence of organic

mental disorders are not known.
• 5-15% of all patients in medical and surgical
inpatient unit are estimated to develop
delirium at some time in their lives
 Etiology:
• V: Vascular- Hypertensive encephalopathy, cerebral
arteriosclerosis, shock.
• I: Infections –Encephalitis, meningitis and several pareses.
• N: Neoplastic- Space occupying lesions, gliomas,
abscesses.
• D: Degenerative- Senile and presenile dementia,
Alzheimer’s, pick.
• I: Intoxication- Chronic intoxication, bromides, opiates,
tranquilizers, anticholinergics.
• C: Congenital- Epilepsy and postictal status, aneurysm.
• T: Traumatic – Subdural and epidural hematoma,
confusion
• I: Intraventricular- Normal pressure hydrocephalus
• V: Vitamin- Deficiencies of thiamine, niacin and B 12.
• E: Endocrine- Metabolic- Diabetic coma and shock,
uremia, myxedema, acid-base disturbance and auto
immune disorders.
• M: Metals- Hypoxia and anoxia secondary to
pulmonary/ cardiac failure, anemia, etc.
• D: Depression- Depressive pseudo dementia,
hysteria, , postoperative status, sleep deprivation,
heat, electricity and radiation.
 Risk Factors:

• Age • High number of meds

• Cognitive impairment • Sensory impairment
• 25% delirious are demented • Psychoactive medications
• 40% demented in hospital • Use of restraints
delirious • Metabolic disorders:
• Male gender – Azotemia
• Severe illness – Hypo- or hyperglycemia
• Hip fracture – Hypo- or hypernatrmiea
• Fever or hypothermia • Depression
• Hypotension • Alcoholism
• Malnutrition • Pain
 Precipitating risk factors

• Meds • Anemia
• Severe acute illness • Pain
• UTI • Orthopedic surgery
• Hyponatremia • Cardiac surgery
• Hypoxemia • ICU admission
• Shock • High number of hospital
procedures
 The pathophysiology of delirium
• Many hypotheses exist including:
• Neurotransmitter abnormalities
• Inflammatory response with increased cytokines
• Changes in the blood-brain barrier permeability
• Widespread reduction of cerebral oxidative
metabolism
• Increased activity of the hypothalamic-pituitary
adrenal axis.
 Theories for Post Op Delirium
• Acetylcholine interaction with medications
used during surgery
• Increase of neurotransmitters, serotonin and
dopamine during surgery
• Previous abnormality levels of melatonin
• Damage to neurons by oxidative stress or
inflammation caused by a surgical procedure
• Post op abnormal brain waves
 Clinical feature

• Acute onset, clouding of consciousness,

characterized by a decreased awareness of
surroundings and a decreased ability to
respond to environment stimuli.
• Disorientation- decreased attention span
• Distractibility
• Illusions, hallucinations also occur.
• Marked perceptual disturbance
 Contd……
• Disturbance of the sleep
• Diurnal variation is marked, usually with
worsening of symptoms in the evening and night
– sun downing
• Impairment of registration and retention of new
memories.
• Psycho motor disturbance- form of agitation and
occasionally retardation.
• Tone and reflex abnormalities.
• Speech and thought disturbances- slurring
of speech, dysarthria, fleeting delusions
• Motor symptoms
• Asterixis- flapping tremor
• Multifocal myoclonus
• Carphologia or floccillation- picking
movements at cover
• Occupational delirium
 Clinical Picture of Delirium

Patterns of presentation:
1. Over activity manifesting as:
restlessness, irritability, oversensitivity to stimuli, noisiness, and
psychotic symptoms

2. Under activity manifesting as:

calmness, lethargy, inactivity, slowness, reduced speech,
perseveration with few psychotic symptoms
 Differential Diagnosis
– Dementia, particularly frontal lobe
– Other Psychiatric disorders
• Psychosis
– Depression: 41% misdiagnosed as depression
– A convulsive status epilepticus
– Akathisia
– Overall, 32-67% missed or misdiagnosed
 Course and Prognosis

 Usually reversible
 Symptoms usually recede over 3-7 days period, but may last less
than hour or more than a week
 Mortality rate may reach 10-15%
Assessing for Delirium
 Diagnosis DSM –IV CRITERIA

A. Disturbance of consciousness with reduced ability

to focus, sustain, or shift attention
B. A change in cognition or the development of a
perceptual disturbance that is not better accounted
for by a pre-existing, established, or evolving
dementia.
C. The disturbance develops over a short period of
time and tends to fluctuate during the course of
the day
D. There is evidence from the history, PE, or labs that
the disturbance is caused by the direct physiologic
consequences of a general medical condition
 Physical Exam
– Vitals: normal range of BP, HR, Temp and pain

– Good physical exam: particular emphasis on

Cardiac, pulmonary and neurologic systems

– Hydration status

– Also rule out

• fecal impaction
• urinary retention
• Infected pressure ulcer, UTI or pneumonia
Delirium workup: Lab testing
• Basic labs most helpful!
– CBC,electrolytes, BUN/Cr,
glucose,CO2, Ca+, Mg,
PO4
– TSH, B-12, LFTs &
albumin

• Infection workup
(Urinalysis, CXR) +/- blood
cultures

• EKG

• O2 sat/ABG
 Management
Four key steps in management of delirium are:
Addressing the underlying causes.
Maintaining behavioral control,
Prevention complication,
Supporting functional needs
 Aim of treatment:
Correcting the physiological disturbance
Treating the electrolyte imbalance
 TREATMENT OF DELIRIUM

• Identify,correct cause(s)-o/f multifactorial

• Haloperidol-for sleep
disturbance+agitation, 5-10 mg HS

• Lorazepam-best in alcohol withdrawl,

hepatic encephalopathy
• Physostigmine 1-2mg slow I/ V or I/ M in
anticholinergic delirium

• Benzodiazepines often worsen delirium

 TREATMENT…contd
Minimise danger-never unattended
familiar bedside figure
-orient staff
-restrict visitors
-bed rails
-no reachable dangerous objects
Optimise sensory environment
-lighting
-quiet room
-calendar,clock
 Outcomes of Delirium

35% 40%

25%

Recovery Permanent Cognitive Impairment Mortality

(even with complete recovery, 30% dementia within 3 years = decreased

brain reserve)
Nursing management
 Nursing diagnosis
• Risk for trauma related to impairment in
cognitive and psychomotor function
• Disturbed thought process related to cerebral
degeneration as evidenced by disorientation,
confusion, memory deficits and inaccurate
interpretation of the environment.
• Self-care deficit related to disorientation,
confusion and memory deficit as evidenced by
inability to fulfill the ADL.
 Other nursing diagnoses

• Acute Confusion
• Additional diagnoses that are commonly selected
based on client assessment include the following:
• Disturbed Sensory Perception
• Disturbed Thought Processes
• Disturbed Sleep Pattern
• Risk for Deficient Fluid Volume
• Risk for Imbalanced Nutrition: Less Than Body
Requirements
 Nursing interventions
• Promoting client’s safety
• Teach client to request assistance for activities
(getting out of bed, going to bathroom).
• Provide close supervision to ensure safety
during these activities.
• Promptly respond to client’s call for
assistance.
Managing client’s confusion
• Speak to client in a calm manner in a clear low
voice; use simple sentences.
• Allow adequate time for client to comprehend
and respond.
• Allow client to make decisions as much as
able.
• Provide orienting verbal cues when talking
with client.
• Use supportive touch if appropriate.
 Controlling environment to reduce sensory
overload
• Keep environmental noise to minimum
(television, radio).
• Monitor client’s response to visitors; explain
to family and friends that client may need to
visit quietly one on one.
• Validate client’s anxiety and fears, but do not
reinforce misperceptions.
• Promoting sleep and proper nutrition
• Monitor sleep and elimination patterns.
• Monitor food and fluid intake; provide prompts or
assistance to eat and drink adequate amounts of
flood and fluids.
• Provide periodic assistance to bathroom if client
does not make requests.
• Discourage daytime napping to help sleep at night.
• Encourage some exercise during day like sitting in a
chair, walking in hall, or other activities client can
manage.
 What causes delirium?

Dementia
Electrolytes
Lungs, liver, heart, kidney, brain
Infection
Rx (especially medications)
Injury, pain, stress
Unfamiliar environment
Metabolic
Inouye SK. Conn Med1993;57:309-15
 Differentiating Acute Delirium from
Chronic Dementia
Feature Delirium Dementia
Onset Acute Insidious
Duration Brief Chronic, unless
reversible
Consciousness fluctuates static
Orientation Abnormal Normal in mild
cases
Memory Recent defective Recent/later loss
Initial ST loss
 Delirium vs. dementia cont…
Attention Always May be intact
impaired
Perception Freq. Disturbed Flat empty talk
Thinking Disorganized, Impaired,
contents rich contents empty
Judgment Poor poor
Insight Present in lucid May be absent
intervals
Sleep Always Variable
disturbed