1. Organic Mental Disorders Delirium Dementia Organic Amnestic Syndrome Other Organic Mental Disorders

2. Organic – due to Primary Brain Pathology Secondary Brain Dysfunction to Systemic Disease Suspicion of organic mental disorder : 1. First Episode 2. Sudden Onset 3. Older Age at onset 4. Hx of Drug/Alcohol abuse 5. Concurrent medical/neurological problem 6. Neurological signs: Seizures, LOC, Head injury, sensory motor deficit. 7. Presence of Confusion/Disorientation 8. Presence of visual and non auditory (olfactory, gustatory, tactile) hallucinations

3. A. DELIRIUM Commonest organic mental disorder Definition: Acute organic brain syndrome characterized by clouding of consciousness and disorientation develops over a brief period and remits immediately once offending cause is removed. Epidemiology: - 5 to 15% of medical & surgical px; - High in post op patients; - 40-50% recovering from hip surgery; - Highest rate in post cardiotomy patients; - 30% in ICU

4. Clinical Features Acute Clouding of conciousness Disorientation (mostly time, severe cases place and person) Short attention span/distractibility Perceptual Distortion Disturbance in sleep wake cycle DECREASE AWARENESS TO SURROUNDING DECREASE ABILITY TO RESPOND TO ENVIRONMENTAL STIMULI ILLUSIONS HALLUCINATIONS Mostly Visual INSOMNIA DAY TIME SLEEPINESS

5. Sun Downing – six in evening New Memory Impairement Relatively intact remote memory Speech Mood – Fear, anger rage Delusions – Fleeting and fragmentary Neuro: Tremors, Dysphasia, Urinary incontinence IMPAIRED IMMEDIATE RECALL IMPAIRED RECENT MEMORY SLURRING of SPEECH INCOHERANCE

6. Predisposing Factors Old age Pre existing brain damage/dementia Past history of delirium Alcohol /drug dependence Chronic Medical illness Surgical procedures History of Head Injury

7. Organic ETIOLOGY of Delirium

8. Management of Delirium If cause not known – Do a battery of investigations : CBC, Urinalysis, Blood glucose, Blood urea serum analysis, Liver and renal function test, arterial p02, Pco2, Thyroid function, B12, Folate levels, CSF, ECG, Drug screen,HIV, EEG, CT & MRI Correct underlying cause – If underlying cause is found then it must be treated immediately . For ex 50mg of 50% IV dextrose for HYPOGLYCEMIA 02 for HYPOXIA IV fluids for electrolyte imbalance

10. Small dose BENZODIAZEPINES (Lorazepam, Diazepam)

11. ANTIPSYCHOTIC (Haloperidol)MAINTAIN WITH ORAL HALOPERIDOL, LORAZEPAM TILL RECOVERY IN 1 WEEK REVIEW DOSE, TAPER AND STOP

12. DELIRIUM VS DEMENTIA

13. B. DEMENTIA

15. Aphasia – Difficulty in naming an object Hallucinations and Delusions Additional:- - Emotional lability: Marked variable emotional expression - Catastrophic rxn: When asked to do something beyond her intellectual capibility, she goes into a rage

16. Types and causes Of Dementia Commonest: ALZHEIMERS DEMENTIA, MULTIINFARCT DEMENTIA, HYPOTHYROID DEMENTIA, AIDS DEMENTIA COMPLEX

17. ALZHEIMER’S DEMENTIA Women, Genetic ↓ neurotransmitter AcetylCholine due to degeneration of cholinergic nuclei in basal forebrain Drugs: Rivastigmine (1.5-6mg/day), Galantamine (4-12mg BID) -> ↑Ach by slowing its degredation Memantine (5-20mg/day) -> N, Methyl D Aspartate (NMDA) antagonist Vitamin E

19. Abrupt onset, Acute exacerbations, Step wise clinical deterioration, Fluctuating course

20. Focal Neurological signs

21. Investigations: EEG (focal area of slowing) CT brain (multiple infarct area)

22. Treatment: Underlying (eg HPT)TIA HPT CVS DISEASE PREVIOUS STROKE

23. AIDS DEMENTIA COMPLEX 50-70% patient of AIDS Triad of cognigtive, behavioral, motoric deficits, -> subcortical dementia Virus cross BBB -> Cognitive impairement Ix ELISA, Western Blot CT may show cortical atrophy

24. MANAGEMENT OF DEMENTIA Basic investigations Treat underlying cause – mentioned Symptomatic management of anxiety, depression, Psychotic symptoms Education – Family, Financial, Support groups Institutionalize in later stage

26. Memory impairment (anterograde, retrograde amnesia) due to an underlying organic cause.

27. No impairment of global intellectual function,abstract thinking,personality.

28. Caused by Thiamine deficiency in alcohol dependence as part of Wernicke Korsakoff Syndrome

30. Management Treat the underlying cause if treatable.Ususally treatment is of not much help,except in prevention of further deterioration and the prognosis is poor

31. D. Other Organic Mental Disorders Organic Hallucinosis Organic Catatonic Disorder Organic Delusional (Schizo like) disorder Organic Personality Disorder

32. Organic Hallucinosis Etiology: Drugs:Hallucinogens,cocaine,cannabis,bromide) Alcohol:In alcoholic hallucinosis,auditory hallucinations are more common Migraine Epilepsy: Complex partial seizures Brain stem lesions

33. Persistant or recurrent hallucinations due to an underlying organic cause. No major disruption of consciousness, intelligence or memory Management 1)Treatment of the underlying cause if treatable. 2) Symptomatic treatment with a low dose of an anti-psychotic drug.

34. Organic Catatonic Disorder Etiology: Neurologic disorders: limbic encephalitis,Surgical procedures,sub dural hematoma,cerebral malaria Systemic and metabolic disorders : Diabetic ketoacidosis , pellagra, SLE, Hepatic encephalopathy Drugs and poisoning: Organic alkoloids ,aspirin,lithium poisoning ,ethyl alcohol , co Psychiatric disorders : manic stupor , periodic catatonia , reactive psychosis ,schizophrenia

35. Management Treatment of underlying cause Symptomatic treatment with low doses of benzodiazipam or an anti-psychotic or electro convulsive therapy.

36. Organic delusional disorder Predominant delusions which are persistant or recurrent ,caused by an underlying organic cause. No major disturbance of consciousness,orientation , memory or mood. Etiology: Drugs:Amphetamines,cannabis,disulfimes Spino cerebellar degeneration Complex partial seizures

37. Management Treatment of underlying cause Symptomatic treatment with low doses of benzodiazipam or an anti-psychotic or electro convulsive therapy.