organic mental disorders maria l.a. tiamson, md asst. professor, psychiatry new york medical college
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ORGANIC MENTAL DISORDERS
Maria L.A. Tiamson, MDMaria L.A. Tiamson, MD
Asst. Professor, PsychiatryAsst. Professor, Psychiatry
New York Medical CollegeNew York Medical College
DeliriumDelirium DementiaDementia Amnestic DisordersAmnestic Disorders Subcategories:Subcategories:
caused by general medical condition, caused by general medical condition, substance use or NOSsubstance use or NOS
Common Primary Symptom: cognitive Common Primary Symptom: cognitive impairmentimpairment
DSM-IV
DELIRIUM
CORE SYMPTOM: impairment of CORE SYMPTOM: impairment of consciousness, ie. reduced ability to focus, consciousness, ie. reduced ability to focus, sustain or shift attentionsustain or shift attention
acute onset and fluctuatesacute onset and fluctuates direct physiologic consequences of a direct physiologic consequences of a
general medical conditiongeneral medical condition a a MEDICAL EMERGENCYMEDICAL EMERGENCY !!! !!!
Epidemiology of Delirium
15-18% of med-surg15-18% of med-surg 30% of post-CABG30% of post-CABG 50% of post-hip surgery50% of post-hip surgery frequently misdiagnosedfrequently misdiagnosed
Risk Factors of Delirium
extremes of age (old & young)extremes of age (old & young) burns (3rd degree)burns (3rd degree) post-cardiotomy patientspost-cardiotomy patients drug dependencedrug dependence HIV/AIDSHIV/AIDS pre-existing brain damagepre-existing brain damage history of deliriumhistory of delirium
URGENT Diagnosis
WWithdrawal/Wernicke’sithdrawal/Wernicke’s HHypertensive encephalopathyypertensive encephalopathy HHypoglycemiaypoglycemia HHypoperfusion of CNSypoperfusion of CNS HHypoxemiaypoxemia IIntracranial bleedntracranial bleed MMeningitis/encephalitiseningitis/encephalitis PPoisons/Medicationsoisons/Medications
Clinical Features of Delirium
ProdromeProdrome Temporal courseTemporal course Attentional deficits and arousalAttentional deficits and arousal OrientationOrientation Language and cognitionLanguage and cognition PerceptionPerception Mood Mood Other symptomsOther symptoms
Clinical Course of Delirium
Diagnosis: rating scales, bedside exam, Diagnosis: rating scales, bedside exam, labs and other diagnostic tests, review of labs and other diagnostic tests, review of medications (including OTC drugs and medications (including OTC drugs and illicit drugsillicit drugs
CourseCourse PrognosisPrognosis
Pathophysiology of Delirium
Areas of the brain affected:Areas of the brain affected: prefrontal cortex, right cerebral hemisphere, prefrontal cortex, right cerebral hemisphere,
subcortical nucleisubcortical nuclei Neurotansmitters affected:Neurotansmitters affected:
acetylcholineacetylcholine dopaminedopamine GABAGABA histaminehistamine
Treatment of Delirium
Etiological: VERY IMPORTANTEtiological: VERY IMPORTANT Symptomatic:Symptomatic:
neurolepticsneuroleptics benzodiazepinesbenzodiazepines
DEMENTIA
Syndrome of acquired persistent Syndrome of acquired persistent impairment in intellectual function: impairment in intellectual function: memory, language, visuospatial skills, memory, language, visuospatial skills, emotion or personality, and cognitionemotion or personality, and cognition
Effect of pathological processes on the Effect of pathological processes on the brain, NOT THE EFFECT OF AGINGbrain, NOT THE EFFECT OF AGING
Epidemiology of Dementia
4 million severe dementia4 million severe dementia 1-5 million mild to moderate1-5 million mild to moderate 50-60% Alzheimer’s dementia50-60% Alzheimer’s dementia 15-30% Vascular dementia15-30% Vascular dementia 1-5% Other causes1-5% Other causes 15% are reversible15% are reversible
Classification of Dementia
CORTICAL: Alzheimer’sCORTICAL: Alzheimer’s SUBCORTICAL: HAD, Parkinson’s, SUBCORTICAL: HAD, Parkinson’s,
Huntington’sHuntington’s MIXED: VascularMIXED: Vascular PseudodementiaPseudodementia
Risk Factors for Dementia
ALZHEIMER’S:ALZHEIMER’S: female, hx of 1st degree relative with AD, hx of female, hx of 1st degree relative with AD, hx of
Down’s, hx of head traumaDown’s, hx of head trauma MULTI-INFARCT DEMENTIA (Vascular):MULTI-INFARCT DEMENTIA (Vascular):
male, HTN, 60-70 y/omale, HTN, 60-70 y/o H.A.D.:H.A.D.:
wasting syndrome, older age at dx, substance wasting syndrome, older age at dx, substance abuse hxabuse hx
Clinical Features of Dementia
MemoryMemory OrientationOrientation Language changesLanguage changes Personality changesPersonality changes Perceptual changesPerceptual changes Other symptomsOther symptoms
Cortical Dementias
AAmnesiamnesia AApraxiapraxia AAphasiaphasia AAgnosiagnosia diffuse atrophy with flattened sulci anf diffuse atrophy with flattened sulci anf
enlarged ventriclesenlarged ventricles senile amyloid plaques, neurofibrillary senile amyloid plaques, neurofibrillary
tanglestangles
Vascular Dementias
Stepwise deterioration of functioningStepwise deterioration of functioning affects small and medium sized cerebral affects small and medium sized cerebral
vesselsvessels multiple parenchymal lesions spread over multiple parenchymal lesions spread over
wide areas of the brainwide areas of the brain
Subcortical Dementia
Apathy, depression, psychomotor Apathy, depression, psychomotor retardationretardation
affects frontal lobe, basal ganglia, thalamusaffects frontal lobe, basal ganglia, thalamus disruption of fundamental cerebral disruption of fundamental cerebral
functions: arousal, attention, motivation and functions: arousal, attention, motivation and rate of information processingrate of information processing
Pseudodementia
Dementia syndrome of depressionDementia syndrome of depression ““don’t know” answers typicaldon’t know” answers typical attention and concentration well preservedattention and concentration well preserved indifference to cognitive impairmentindifference to cognitive impairment
Treatment of Dementia
Etiologic:Etiologic: cholinesterase inhibitors: tacrine, donepezil, cholinesterase inhibitors: tacrine, donepezil,
revastigmine, metrifonaterevastigmine, metrifonate HAARTHAART
Treatment of co-morbid conditions:Treatment of co-morbid conditions: depression, agitation, psychosisdepression, agitation, psychosis
Adjunctive treatments:Adjunctive treatments: vit.E, hydergine, selegeline, ginkgo bilobavit.E, hydergine, selegeline, ginkgo biloba
Treatment of Dementia
Supportive treatmentSupportive treatment creating a safe environmentcreating a safe environment
PsychotherapyPsychotherapy Legal issuesLegal issues
Amnestic Disorders
Single symptom of a memory disturbance Single symptom of a memory disturbance that causes significant impairment in that causes significant impairment in functioningfunctioning
anterograde amnesiaanterograde amnesia retrograde amnesiaretrograde amnesia
Major Causes of Amnesia
Systemic medical conditionsSystemic medical conditions Primary brain conditionsPrimary brain conditions Substance related causesSubstance related causes Affects dorsomedial and midline thalamic Affects dorsomedial and midline thalamic
nuclei, hippocampus, mammilary bodies, nuclei, hippocampus, mammilary bodies, amygdalaamygdala
Treatment of Amnesia
EtiologicalEtiological PsychotherapyPsychotherapy