Transcript Organic Disorders 2

Dementia is an acquired global impairment of
intellect, memory and personality , but without
impairment of consciousness.
 It is usually but not always progressive
 Although dementia is global or generalized
disorder, it often begins with focal cognitive or
behavioral disturbances
 Most common causes: Alzheimer’s disease(5060%), vascular dementia (20-25%), and
dementia with Lewy bodies (15-20%)
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Both DSM-IV and ICD-10 definitions require
impairment in two or more cognitive domains
(memory, language, abstract thinking and
judgment , praxis, visuoperceptual skills,
personality , and social conduct) sufficient to
interfere with social or occupational functioning.
 Deficits may initially be too mild or
circumscribed to fulfill this definition.
 The fluctuation in alertness which characterize
delirium is usually absent , except in dementia
with Lewy bodies.
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Primary neurodegenerative disorders: Alzheimer’s,
Lewy bodies, Pick’s, Parkinson’s, Prion diseses,
Huntington’s disease.
Vascular: vascular dementia, multiple strokes, focal
thalamic and basal ganglia strokes, subdural
hematoma
Inflammatory and autoimmune: SLE, Bahcet’s, MS,
neurosarcoidosis
Traumatic : head injury
Infections and related conditions: HIV, neurosyphilis
Metabolic and endocrine : uremia, dialysis,
hypothyroidism, hypoglycemia, hypopituitarism,
Cushing’s disease
7. Neoplastic
8. Post-radiation
9. Post- anoxic
10. Vitamin and other nutritional deficiencies :
B12, folate
11. Toxic: alcohol , heavy metals, organic
solvents
12. Other causes: normal pressure
hydrocephalus
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The presenting complaint is usually of poor
memory
Other features include disturbances of
behavior, language , personality, mood ,or
perception
Dementia is often exposed by a change in
social circumstances or an intercurrent
illness; indeed,patients with dementia are
specially susceptible for superimposed
delirium.
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Forgetfulness is usually early and prominent
Impaired attention and concentration are common
and non-specific features
Difficulty in new learning is usually the most
conspicuous feature.
Memory loss is more evident for recent than for more
remote material
Loss is more in episodic memory (day-day events)
while there is relative preservation of procedural
memory
Loss of flexibility and adaptability for new situations
with the appearance of rigid and stereotyped routines
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As dementia progress patients became unable to care for
themselves and they neglect social conventions.
Disorientation for time and later for place and person is
common
Behavior become aimless
Thinking slows and become impoverished in content and
perseverative
False ideas often with persecutory kind appear and in
later stages the thinking becomes grossly fragmented
and incoherent
Eventually patient may become mute
Behavioral , affective, and psychotic features accompany
the cognitive deficits during dementia.
Mortality is increased with death often following
bronchopneumonia and a terminal coma
subcortical
cortical
memory
moderate
Severe , early
language
normal
Dysphasias , early
personality
Apathetic, inert
indifferent
mood
Flat, depressed
normal
coordination
impaired
normal
Cognitive and motor speed
slowed
normal
Abnormal movements
Common, choreiform or
tremor
rare
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In all patients: full blood count, ESR, urea
and electrolytes, liver function tests, calcium
and phosphate, thyroid function tests,
syphilis serology, urinalysis, B12 and folate.
Worth considering: HIV status, chest
radiograph , EEG, CT & MRI of brain, ECG,
neuropsychological assessment
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A-Drug therapy for cognitive deficits:
Cholinesterase inhibitors: can decrease the
cognitive defects in 60%of patients like tacrine(
risk of liver damage is high) which lead to
incompliance ,and donepezil( aricept) which has
less severe side effects.
Vitamin E :which can decrease the rate of
functional decline.
Selegiline:MAO B inhibitor which delays cognitive
deterioration . Its major defect is orthostatic
hypotension .No need for dietary restriction.
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B – Drug therapy for psychosis and agitation :
antipsychotic drugs like risperidone and
clozapine. Also benzodiazepines like
lorazepam for sleep disorders.
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Anticonvulsant agents, antiandrogens(
medroxyprogesterone) for disinhibited sexual
behavior.
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C -antidepressants
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Epilepsy is the tendency to recurrent seizures
A seizure is consisting of a paroxysmal
electrical discharge in the brain and its clinical
sequelae.
The tendency to recurrent seizures in
epilepsy should be distinguished from
isolated seizures due to : drugs,
hypoglycemia, and intercurrent illness.
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Psychiatric co-morbidity is common in people with
epilepsy, with overall rates increased at least two
folds.
Many different types of psychiatric disorders are
associated with epilepsy ,including cognitive ,affective
,emotional and behavioral disturbances.
These can occur before, during ,after ,and in between
seizures.
The relationship between epilepsy and psychiatric
disorders can be reflected in : a shared etiology
(temporal lobe pathology can cause both epilepsy and
psychosis), the effects of stigma, and the side effects
of antiepileptic drugs that might cause psychiatric
problems.
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Called prodromal states
Mood disturbances
Increasing tension , irritability
Anxiety and depression
Usually occur several hours or even days
before a seizure ,and usually increasing in
severity as the seizure approaches.
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In complex partial seizures there might be
affective disturbances, hallucinations, anxiety
,automatism
Absence seizures : altered awareness and
automatism
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Impaired consciousness
Delirium
Psychosis
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Not related to the occurrence of fits
Cognitive problems
Psychosis
Sexual problems
Depression
Suicide and deliberate self harm
Personality change
There are two main groups of patients who
have suffered head injury:
1. The relatively small group with persistent
serious cognitive and behavioral sequele
2. A larger group with emotional symptoms
and personality change
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Occur after recovery from coma
Delirium
Delusional misidentification
Agitation and disinhibition
Inappropriate sexual behavior
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Post-concussional syndrome: a group of symptoms include
anxiety, depression and irritability, accompanied by headache,
dizziness, fatigue , poor concentration, and insomnia. It might be
psychologically based and usually resolve spontaneously.
Lasting cognitive impairment: deficits in memory and executive
functions ( planning, problem solving, organizing, etc…)
Personality change: irritability , apathy, loss of spontaneity and
drive, disinhibition, and decreased control of aggressive
impulses.
Emotional disorder: depression , anxiety, and emotional lability.
Psychosis: may be transient or chronic
Boxing and head injury: 10-20% of professional boxers develop
what is called punch drunk syndrome or dementia pugilistica.