organic brain syndromes aric storck resident rounds february 16, 2005
TRANSCRIPT
Organic Brain Syndromes
Aric StorckResident RoundsFebruary 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 SyndromeDefinition (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
DDxInfectious
Systemic– Urinary Tract Infection– Sepsis
Primary CNS– Encephalitis– Meningitis– Central Nervous System Abscess
DDxWithdrawal
Sedative Hypnotics– Alcohol– Benzodiazepines– Barbituates
DDxAcute Metabolic
Acidosis ↑ or ↓ glucose ↑ or ↓ Na ↑ Ca ↓ Mg Renal failure Hepatic failure
DDxTrauma
Head trauma Burns
DDxCNS Disease
Bleeds– SAH, EPH, SDH, ICH
CVA Increased ICP Tumor Seizure Vasculitis Degenerative
DDxHypoxia & Hypercarbia
COPD Pneumonia CO
– Winter, >1 individual Methemoglobinemia
DDxDeficiencies
B12 Thiamine
– Wernicke’s Niacin
DDxEnvironmental / Endocrine
Hypothermia Hyperthermia Hypothyroid DKA / HONK
DDxAcute Vascular
Hypertensive encephalopathy Intracranial bleed Cerebral vein thrombosis
DDxToxins/Drugs
Medications– Anticholinergics– Diuretics– Lithium
Drugs of Abuse– EtOH– Street drugs
DDxHeavy 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
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 2 – the confused smoker…
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 DeliriumDSM - 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
deliriumor
dementia?
Diagnosis of DementiaDSM 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
DementiaED 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 pseudodementiaNB: Classic exam question
Dementia– Insidious onset– No psych history– Demeanor
• Unconcerned• Confabulates• Struggles at tasks
– Attention impaired– Cooperative– Recent>remote memory
loss– Chronic progressive
Pseudodementia– Subacute onset– Psych history– Demeanor
• Distressed• Emphasizes deficits• Limits effort
– 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 PsychosisNB: 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 9O/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