Transcript 2008_02_28-Reed-Organic_brain_syndromes

ORGANIC BRAIN
SYNDROME
Alyssa Reed, R1
February 28, 2008
OBJECTIVES
1. Define Organic Brain Syndromes
2. Approach to Organic Brain Syndromes
3. Delirium vs Dementia
4. Dementia vs Pseudodementia
5. OBS vs Psychiatric Illnesses
Definitions
• Organic Brain Syndrome: loosely defines
a group of cognitive disorders that are
secondary to CNS disease, systemic
disorders, or substance-related disorders
• Acute OBS: delirium
• Chronic OBS: dementia
• Both are a confusional state that
manifest as global cognitive impairment
Definitions
• Global Cognitive Impairment involves all
levels of higher cortical fxn
- behaviour
- emotions
- judgment
- language
- abstract thinking
- psychomotor activity
Delirium
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DSM IV TR
1. Disturbance of consciousness with reduced ability
to focus, sustain, or shift attention
2. Evidence from the Hx, PE, Labs that the
disturbance is caused by a general medical
condition, medication or other substance
exposure, substance withdrawal or multiple
etiologies
3. A change in cognition (memory deficit,
disorientation, language disturbance) or the
development of a perceptual disturbance that is
not accounted for better by a pre-existing,
established, or evolving dementia
4. The disturbance develops over hours to days the
tends to fluctuate during the course of the day
Dementia
• DSM IV TR
1. Memory impairment (impaired ability
to learn new info or to recall
previously learned info)
2. One or more of the following cognitive
disturbances
• aphasia (language disturbance)
• apraxia (impaired motor activity)
• agnosia (failure to recognize and
identify objects)
• disturbance in executive functioning
(ie. planning, organizing,
sequencing, abstracting
3. the course is gradual and continuing
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Delirium Etiology
WATCH DEATH
I: Infection
W: Withdrawal
A: Acute Metabolic
T: Trauma
C: CNS dz
H: Hypoxia/Hypercarbia
D: Deficiencies
E: Environmental/Endocrine
A: Acute Vascular
T: Toxins/Drugs
H: Heavy Metals
DDX
• INFECTIOUS
- Sepsis
- Encephalitis/Meningitis
- CNS Abscess
- Syphilis
• WITHDRAWAL
- EtOH
- Barbiturates
- Benzos
DDX
• ACUTE METABOLIC
- Acidosis
- Electrolyte disturbances
- Hepatic and Renal Failure
• TRAUMA
- Head
- Burns
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DDx
CNS Dz
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Bleeds (SAH, EPH, SDH, ICH)
CVA
Vasculitis
Tumor
Increased ICP
Seizure
HYPOXIA
COPD
Pneumonia
CO
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Methemoglobinemia
DDx
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DEFICIENCIES
B12
Niacin
Thiamine
ENVIRONMENTAL
hypothermia/hyperthermia
ENDOCRINE
thyroid
adrenal
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- DKA/HHS
DDx
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ACUTE VASCULAR
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hypertensive encephalopathy
intracranial bleed
cerebral vein thrombosis
TOXINS/DRUGS
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medications
drugs of abuse
HEAVY METALS
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lead
mercury
Approach
1. Hx
2. Physical Exam
3. Mental status exam
4. Investigations
Hx
MSE
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Poorly done by ED physicians
Usually only orientation to person, place, time
Should include assessment of
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orientation
memory
attention
concentration
constructional tasks
spatial discrimination
arithmetic ability
writing
Score<24
Sensitivity 87%
Specificity 82%
for detecting OBS
Sensitivity of 93-100%
Specificity of 90-95%
Investigations
• Standard
- CBC
- Lytes, Ca, Mg, PO4
- LFTs
- Cr, BUN
- UA
• As Indicated ...
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Investigations
CXR
ABG
CT head
LP
Blood cultures
-Tox screen
-TSH
CASE
•by
47M brought in by EMS who were called
the police who found him outside,
agitated, confused
PMHX: friend says he is on some antidepressant
VS: T= 35.1, P= 120, RR= 15, O2 91%
ra
O/E: not oriented x3, mydriasis, crackles
LLL/RLL
Q: OBS? Which one?
Q: What is your approach?
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DDx
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I WATCH DEATH
I: Infection
W: Withdrawal
A: Acute Metabolic
T: Trauma
C: CNS dz
H: Hypoxia/Hypercarbia
D: Deficiencies
E: Environmental/Endocrine
A: Acute Vascular
T: Toxins/Drugs
H: Heavy Metals
1. Drugs
2. Environment
3. Infection
Pathophysiology of
Delirium
• Disorder of neurotransmission in cortical
and subcortical regions of brainCOMPLEX!!!
1. Neurotransmitter pathways
- increase serum anticholinergic activity
- decrease in acetylcholine production
- increased serotonin levels
2. Deficiencies of substrates for oxidative
metabolism (glucose and oxygen)
3. Increase in cytokines
4. Synthesis of false neurotransmitters
Pathophys cont...
• Specifically for our delirious patient:
- Tricyclics
can cause delirium by
causing cholinergic inhibition
- Hypothermia
likely causes delirium as
a result of changes in the cerebral
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metabolic rate
cerebral metabolism decreases by
6% for each degree celcius <36
certain enzymes cannot fxn
Infection (sepsis) has been
associated with increased serotonin
levels
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•75M brought CASE
in by wife who states he
woke up this morning confused and
disoriented
•PMHX: palliate lung cancer, CVA in 2000,
MI 2004, COPD, HTN
•Meds: metoprolol, coumadin, lasix,
ramipril, spiriva, ASA, recent prednisone
therapy
•Q: OBS?
•Q: DDX?
DDx
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I WATCH DEATH
I: Infection
W: Withdrawal
A: Acute Metabolic
T: Trauma
C: CNS dz
H: Hypoxia/Hypercarbia
D: Deficiencies
E: Environmental/Endocrine
A: Acute Vascular
T: Toxins/Drugs
H: Heavy Metals
Delirium
• RISK FACTORS
- Advanced age
- Dementia or cognitive impairment
- Severe
underlying medical condition
(Ca, AIDS)
- Intoxication with substances
- Psychiatric Illness
- Polypharmacy
- Hospitalization
CASE
• 50F presents with progressive cognitive
dysfunction (reduced memory,
spontaneous speech difficulties),
decreased ADLs, ataxia, and urinary
incontinence
• on no meds, AVSS, baseline labs WNL
• Q: OBS?
• Q: what is this triad classic of?
Dementia
Etiology
•Dementia may be caused by more than
50 different disease states
Approximately 10% of dementias are
reversible
Primary Degenerative:
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1.Alzheimer’s
2.Vascular
3.Lewy Body
4.Subcortical dementias
• PSP (progressive supranuclear palsy)
• Huntington’s chorea
• Parkinson’s
5.Frontal lobe
Dementia in ED
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Goals:
1. Differentiate delirium and dementia
2. Recognize potentially reversible causes of
dementia
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NPH (progressive dementia, ataxia, urinary
incontinence, average age of 60)
Tricyclic antidepressants (anticholinergic
properties)
EtOH (not just Korsakoff’s, multiple types)
Intracerebral mass
Dementia Workup
1. Hx, PE, MSE
2. Labs
• CBC, lytes, LFTs, UA, TSH, B12
3. Imaging
• CXR
• Head CT
4. Additional
CASE
•70F who recently lost her husband of 48
years is brought in by her daughter who
has noticed for the last month that she
has become unable to dress herself, and
is waking up very early
•PMHx: post-partum depression, MI,
NIDDM
•O/E: AVSS, flat affect, not oriented to
time, unable to identify a pen
•Q: Is this an organic brain syndrome?
Organic Brain Syndrome: loosely defines a group
of cognitive disorders that are secondary to CNS
disease, systemic disorders, or substance-related
disorders
Which
one?
• DEMENTIA
- Insidious onset
- no psych history
- demeanor
• unconcerned
• confabulates
• struggles at tasks
- attention impaired
- cooperative
- recent>remote memory loss
Dementia vs
Pseudodementia
• PSEUDODEMENTIA
- Subacute onset
- Psych hx
- Demeanor
• distressed
** responds to tx
CASE
• 22M brought in by mom who states he
has been increasingly self isolated,
suspicious and irritable. Seems to talk
to people who aren’t there.
• PMHx: none
• O/E: 95 16 120/86 37.1 99% 7.1, no
other findings
• MSE: oriented to person but not time or
place, disorganized, tangential
• LABS: bloodwork normal, marijuana
and cocaine +
• DELIRIUM
- Acute
- AbN VS Delirium vs
- No psych hx
- +/- involuntary
muscle activity (asterixis, tremor)
Pscychosis
- Disoriented
- Visual,
Auditory, Gustatory, Tactile, Olfactory
Hallucinations
• PSYCHOSIS
- Acute
- Normal VS
- Psych Hx
- No involuntary muscle activity
- May be oriented
CASE
• 82F
sent in from Lodge who send a
note saying she is lethargic, not coming
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to meals. She has no complaints.
PMHx: vascular dementia
O/E: 102 16 108/60 93% 36.7 7.4
Q: Approach to the elderly patient with
vague complaints?
1. Complete PE
2. CBC, lytes, Cr, BUN, LFTs
3. CXR, ECG
4. Urine R+M