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