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 patients 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
Huntingtons 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
Cushings
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
Alzheimers 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 Alzheimers 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, 3
rd
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, 3
rd
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, 3
rd
edition

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