Transcript Organic Brain Syndromes - Calgary Emergency Medicine

Organic Brain
Syndromes
Aric Storck
Resident Rounds
February 16, 2005
Objectives

Approach to organic brain syndromes

Delirium vs dementia

OBS vs Psych

Common presentations

Will not discuss treatment

Not evidence based
Organic Brain Syndrome
Definition (Rosen)

Abnormal cognitive state
– Defining feature = confusion

Global cognitive impairment
–
–
–
–
–
–

Disordered behaviour
Emotions
judgment
Language
Abstract thinking
Psychomotor activity
Lots of underlying disorders
– CNS disease
– Systemic disorders
– Toxicologic
definitions continued …

Acute Organic Brain Syndrome
– Delirium

Chronic Organic Brain Syndrome
– Dementia
Case 1

89F
–
–
–
–

Independent until six weeks ago
Now confused
Poor memory
Suspicious and bizarre behaviour
VS 84 12 145/89 99% 37.4
– Antagonistic – thinks you’re there to kidnap her
– Will not let you examine her
What else do you want to know?

Blood glucose 6.4
– Never forget the “6th vital sign”

PMHx
– Cholecystectomy, hysterectomy
– No psychiatric illness
– No dementia

Meds
– ASA, amlodipine, coumadin
– Started Aricept last week
What is your approach?

DDx
– Top three?

OBS vs Functional?

Management
–
–
–
–
–
CT head ?
Labs ?
Haldol ?
Crisis Team to see ?
Long term placement ?
Differential Diagnosis

I WATCH DEATH
–
–
–
–
–
–
–
–
–
–
–
Infectious
Withdrawal
Acute Metabolic
Trauma
CNS disease
Hypoxia/hypercarbia
Deficiencies
Environmental/Endocrine
Acute Vascular
Toxins/Drugs
Heavy Metal
DDx
Infectious

Systemic
– Urinary Tract Infection
– Sepsis

Primary CNS
– Encephalitis
– Meningitis
– Central Nervous System Abscess
DDx
Withdrawal

Sedative Hypnotics
– Alcohol
– Benzodiazepines
– Barbituates
DDx
Acute Metabolic
Acidosis
 ↑ or ↓ glucose
 ↑ or ↓ Na
 ↑ Ca
 ↓ Mg
 Renal failure
 Hepatic failure

DDx
Trauma
Head trauma
 Burns

DDx
CNS Disease

Bleeds
– SAH, EPH, SDH, ICH
CVA
 Increased ICP
 Tumor
 Seizure
 Vasculitis
 Degenerative

DDx
Hypoxia & Hypercarbia
COPD
 Pneumonia
 CO

– Winter, >1 individual

Methemoglobinemia
DDx
Deficiencies
B12
 Thiamine

– Wernicke’s

Niacin
DDx
Environmental / Endocrine
Hypothermia
 Hyperthermia
 Hypothyroid
 DKA / HONK

DDx
Acute Vascular
Hypertensive encephalopathy
 Intracranial bleed
 Cerebral vein thrombosis

DDx
Toxins/Drugs

Medications
– Anticholinergics
– Diuretics
– Lithium

Drugs of Abuse
– EtOH
– Street drugs
DDx
Heavy Metals

Mercury
– “Mad as a hatter….”

Lead
Case 2

67M
– Progressively confused and lethargic x 2
days
– Heavy smoker
• Takes orange, green, blue puffers
– Has runny nose, cough, chills
Case 2 – the confused smoker…

DDx
– Top three?

What helps you
narrow your DDx?

I WATCH DEATH
–
–
–
–
–
–
–
–
–
–
–
Infectious
Withdrawal
Acute Metabolic
Trauma
CNS disease
Hypoxia/hypercarbia
Deficiencies
Environmental/Endocrine
Acute Vascular
Toxins/Drugs
Heavy Metal
Case 2 – the confused smoker…
VS 110 22 110/60 87% 38.1
 Prolonged expiratory phase & wheeze
 ABG 7.25 / 57 / 59 / 25


Diagnosis?
– Hypoxia + Hypercarbia
• member of the 50/50 club
– COPD exacerbation
Case 3

73F
– lives with husband
– Progressively confused x 2 days
• Worse at night
– Lethargic
– Diaphoretic
– Breathing funny

PMHx
– Arthritis

Meds
– Tylenol, ASA, OTC cold medicine
Criteria for Delirium
DSM - IV

Disturbance of consciousness

Change in cognition
– Memory deficit, disorientation, perceptual
disturbance

Develops over short period
– May fluctuate
Back to Case 3


Is this dementia or
delirium?
DDx
– Top 3?
– What else do you
want to know

I WATCH DEATH
–
–
–
–
–
–
–
–
–
–
–
Infectious
Withdrawal
Acute Metabolic
Trauma
CNS disease
Hypoxia/hypercarbia
Deficiencies
Environmental/Endocrine
Acute Vascular
Toxins/Drugs
Heavy Metal
Case 3
O/E 115 38 91/54 38.7 94%
 Disoriented & agitated
 Diaphoretic
 Breathing very deeply


ABG 7.51 / 11 / 134 / 11
I WATCH DEATH
Infectious
 Withdrawal
 Acute Metabolic
 Trauma
 CNS disease
 Hypoxia /
hypercarbia

Deficiencies
 Environmental /
Endocrine
 Acute Vascular
 Toxins/Drugs
 Heavy Metal

Unrecognized adult salicylate intoxication.
Anderson RJ, Potts DE, Gabow PA, Rumack BH, Schrier RW.
Ann Intern Med. 1976 Dec;85(6):745-8.

N =73 - salicylate toxicity
– 27% undiagnosed 72 h after admission
– 60% neurologic consultation before diagnosis
– No difference in labs, physical features of
diagnosed and misdiagnosed patients
– Most misdiagnosed patients elderly, chronic
unintentional overdoses
– Mortality greater with delayed diagnosis
Case 4

82F – from a lodge
– Not answering telephone
– Lethargic
– Unable to walk
– Not coming to meals
– No fever / cough / dysuria / pain
Approach to elderly patient with
vague complaints

Complete physical
exam
 CBC, lytes, Cr, BUN
 LFT’s
 CXR
 Urine R&M

DDX
– Top 3?

I WATCH DEATH
–
–
–
–
–
–
–
–
–
–
–
Infectious
Withdrawal
Acute Metabolic
Trauma
CNS disease
Hypoxia/hypercarbia
Deficiencies
Environmental/Endocrine
Acute Vascular
Toxins/Drugs
Heavy Metal
Case 4

102 16 99/60 93% 36.0 BG7.4
– Chest clear
– Some suprapubic discomfort

Urine – WBC>30, +leuks, +nitrites

Diagnosis?
– Infectious
– Urinary tract infection
Case 4

78F
– Living at home
– More forgetful recently
• Remembers daughter
• Did not recognize grandchildren
– Difficulty cooking and caring for self
– Has left stove on
– Daughter is concerned
Is this
delirium
or
dementia?
Diagnosis of Dementia
DSM IV

Development of multiple cognitive deficits
manifested by both:
– Memory impairment
– One of
•
•
•
•

Aphasia
Apraxia
Agnosia
Poor executive functioning
Deficits cause impairment in functioning
 Deficits do not occur exclusively during
course of a delirium
Delirium vs Dementia
(classic exam question)
delirium
dementia
onset
hours – days
months – years
LOC
altered
Usually normal
Autonomic
disturbances
Frequent
Infrequent
orientation
+/-
+/-
perception
May be abnormal Usually normal
course
reversible
Usually
irreversible
Delirium - Making the Diagnosis
Confusional Assessment Method (CAM)
– Validated tool
– Distinguishes delirium vs dementia
– Based on DSM-IIIR
– Sensitivity 94-100%
– Specificity 90-95%
– Gold Standard = Psychiatrist
Dementia

Insidious onset – may be unrecognized

Usually brought by family following an
acute change

~40% of dementia admitted to hospital
also has a delirium
Dementias

Cortical Dementias
– Alzheimer’s disease
• >50% of all dementia
• Insidious onset
• Social skills maintained until advanced
– Pick’s disease
• Frontal lobe release
Subcortical dementias

Basal Ganglia
– Parkinsons, Huntingtons, Supranuclear Palsy
– Movement disordered

Multi-infarct dementia
– ~20%
– Progressive stepwise deterioration

Infection
– Slow viruses (including HIV)

Dementia pugilistica
 CJD
 >50 other causes
Dementia
ED Workup


Goal
– Differentiate delirium
and dementia
– Recognize
potentially reversible
causes of dementia
•
•
•
•
•
Infection
Medications
NPH
Intracerebral mass
pseudodementia






Hx & Px
Review of meds
Basic bloodwork
Urinalysis
TSH
CXR
+/- CT head
Case 5

79M
– Lives alone since wife passed away
– Brought by daughter
– Poor memory
– Not answering phone
– Doesn’t cook, doesn’t eat
– Losing weight
– Not sleeping regularly
Dementia vs pseudodementia
NB: Classic exam question

Dementia
– Insidious onset
– No psych history
– Demeanor

Pseudodementia
– Subacute onset
– Psych history
– Demeanor
• Unconcerned
• Confabulates
• Struggles at tasks
• Distressed
• Emphasizes deficits
• Limits effort
– Attention impaired
– Cooperative
– Recent>remote memory
loss
– Chronic progressive
– Attention preserved
– Poor effort
– Recent & remote
memory loss
– Responds to treatment
Case 6

38M
– Brought in by police
– Walking downtown naked
– Says George Bush has blessed him
– Sadaam Hussein talks to him at night
– When he dies he is going to “forever”
Case 6

O/E 95 16 120/80 37.0 99% BG7.1
 Happy to let you examine him since “God
ordained my body”
 Normal physical exam
 MSE
– Oriented to person, place, time
– Disorganized & tangential

Normal bloodwork
 Urine tox screen
– +marijuana, +cocaine
Case 6


?OBS

DDx
– Top 3

Investigations?

Management?
I WATCH DEATH
–
–
–
–
–
–
–
–
–
–
–
Infectious
Withdrawal
Acute Metabolic
Trauma
CNS disease
Hypoxia/hypercarbia
Deficiencies
Environmental/Endocrine
Acute Vascular
Toxins/Drugs
Heavy Metal
Delirium vs Primary Psychosis
NB: another classic exam question

Delirium
–
–
–
–
Acute
Abnormal VS
No psych hx
+/- involuntary muscle
activity
– disoriented
– visual, & auditory
hallucinations

Psychosis
–
–
–
–
Acute
Normal VS
Psych hx
No involuntary muscle
activity
– May be oriented
– Auditory hallucinations
Case 7

24M
– Found by mother in bed – didn’t get up
– Confused and combative
– Making jerky arm movements

PMHx
– Depression

Meds
– A little white pill. Mom thinks it’s an antidepressant
Case 7

O/E
–
–
–
–
–
–
–
–
130 20 170/105 38.6 95%
Diaphoretic,
GCS E2 V2 M4
pupils 6mm & reactive
no memingismus
resp/cvs/abd normal
fine tremor
increased tone
symmetrically
– +clonus

Investigations
–
–
–
–
CBC, lytes, AG normal
tox screen neg
ecg normal
cxr normal
Case 7





DDX
– ?Top 3
serotonin syndrome
NMS
sympathomimetic
anticholinergic

I WATCH DEATH
–
–
–
–
–
–
–
–
–
–
–
Infectious
Withdrawal
Acute Metabolic
Trauma
CNS disease
Hypoxia/hypercarbia
Deficiencies
Environmental/Endocrine
Acute Vascular
Toxins/Drugs
Heavy Metal
Syndromes with altered
mentation and hypertonia
Serotonin syndrome
 Malignant hyperthermia
 Neuroleptic malignant syndrome
 thyrotoxicosis
 heatstroke
 CNS hemorrhage
 tetanus

EMR March 1999
Case 7 - Serotonin Syndrome

Disorder involving
– Cognitive-behavioural
• confusion, disorientation, agitation, restlessness
– Autonomic dysfunction
• hyperthermia, diaphoresis, tachycardia
– Neuromuscular symptoms
• myoclonus, hyperreflexia, rigidity

Treatment
– ABCs
– Benzos for neuromuscular symptoms (titrate to effect)
– consider serotonin receptor antagonists (cyproheptadine)
Case 8

28F
–
–
–
–
–

Frequent ED visits for “panic attacks”
SOB with chest pain
Onset 30 min ago on phone with ex-boyfriend
Boyfriend called 911
Same as prior attacks according to chart
PMHx
–
–
–
–
Panic Disorder
Depression
Frequent ED user
Multiple psych admissions
Case 8

OE
– VS 120 30 90/55 37.4 90%
– Looks anxious
– CVS
• Tachycardic, normal HS
– Chest
• breathing fast
– Confused
• can’t give a good history

What else to you want?
What’s going on?

DDx
– OBS vs psych
– Top three


Sats fall to 85%
BP 80/45
D-dimer +

Diagnosis

– PE
– Hypoxia

I WATCH DEATH
–
–
–
–
–
–
–
–
–
–
–
Infectious
Withdrawal
Acute Metabolic
Trauma
CNS disease
Hypoxia/hypercarbia
Deficiencies
Environmental/Endocrine
Acute Vascular
Toxins/Drugs
Heavy Metal
Case 9

84 F
– sent from nursing home (Dementia Unit)
– Baseline
• Non verbal, needs to be fed, walks with
assistance, some recognition of daughter
– Today
• Refusing to eat, not walking
PMH: Alzheimer’s, glaucoma, restless
legs, bipolar disease.
 Meds: Tylenol, Norvasc

Case 9
 O/E
– VS 80 16 120/80 97% 37.2 c/s 5.1
– Agitated, incomprehensible sounds
– CVS – NS
– Chest – mild bibasilar rales
– JVP - ?up
– Abdo – soft, +BS, NT

What else do you want?
Case 9
Delirium on Dementia
Common
 Difficult to sort out what’s new
 Precipitating events

– Pain
• ischemic gut, AMI, AAA
– Dehydration
– Infection
• UTI
• Pneumonia
The end
Meds that cause delirium
Folstein Mini-Mental Status
Examination
Folstein MMSE

ACEP guidelines
– Advocate using in altered mental status

Passing grade 24/30

Screening tool – non-specific