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Organic Brain Syndromes

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).

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Organic Brain Syndromes

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  1. Organic Brain Syndromes Aric Storck Resident Rounds February 16, 2005

  2. Objectives • Approach to organic brain syndromes • Delirium vs dementia • OBS vs Psych • Common presentations • Will not discuss treatment • Not evidence based

  3. 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

  4. definitions continued … • Acute Organic Brain Syndrome • Delirium • Chronic Organic Brain Syndrome • Dementia

  5. 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

  6. 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

  7. DDx Top three? OBS vs Functional? Management CT head ? Labs ? Haldol ? Crisis Team to see ? Long term placement ? What is your approach?

  8. Differential Diagnosis • I WATCH DEATH • Infectious • Withdrawal • Acute Metabolic • Trauma • CNS disease • Hypoxia/hypercarbia • Deficiencies • Environmental/Endocrine • Acute Vascular • Toxins/Drugs • Heavy Metal

  9. DDxInfectious • Systemic • Urinary Tract Infection • Sepsis • Primary CNS • Encephalitis • Meningitis • Central Nervous System Abscess

  10. DDxWithdrawal • Sedative Hypnotics • Alcohol • Benzodiazepines • Barbituates

  11. DDxAcute Metabolic • Acidosis • ↑ or ↓ glucose • ↑ or ↓ Na • ↑ Ca • ↓ Mg • Renal failure • Hepatic failure

  12. DDxTrauma • Head trauma • Burns

  13. DDxCNS Disease • Bleeds • SAH, EPH, SDH, ICH • CVA • Increased ICP • Tumor • Seizure • Vasculitis • Degenerative

  14. DDxHypoxia & Hypercarbia • COPD • Pneumonia • CO • Winter, >1 individual • Methemoglobinemia

  15. DDxDeficiencies • B12 • Thiamine • Wernicke’s • Niacin

  16. DDxEnvironmental / Endocrine • Hypothermia • Hyperthermia • Hypothyroid • DKA / HONK

  17. DDxAcute Vascular • Hypertensive encephalopathy • Intracranial bleed • Cerebral vein thrombosis

  18. DDxToxins/Drugs • Medications • Anticholinergics • Diuretics • Lithium • Drugs of Abuse • EtOH • Street drugs

  19. DDxHeavy Metals • Mercury • “Mad as a hatter….” • Lead

  20. Case 2 • 67M • Progressively confused and lethargic x 2 days • Heavy smoker • Takes orange, green, blue puffers • Has runny nose, cough, chills

  21. 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…

  22. 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

  23. 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

  24. Criteria for DeliriumDSM - IV • Disturbance of consciousness • Change in cognition • Memory deficit, disorientation, perceptual disturbance • Develops over short period • May fluctuate

  25. 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 Back to Case 3

  26. Case 3 • O/E 115 38 91/54 38.7 94% • Disoriented & agitated • Diaphoretic • Breathing very deeply • ABG 7.51 / 11 / 134 / 11

  27. Infectious Withdrawal Acute Metabolic Trauma CNS disease Hypoxia / hypercarbia Deficiencies Environmental / Endocrine Acute Vascular Toxins/Drugs Heavy Metal I WATCH DEATH

  28. 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

  29. Case 4 • 82F – from a lodge • Not answering telephone • Lethargic • Unable to walk • Not coming to meals • No fever / cough / dysuria / pain

  30. 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 Approach to elderly patient with vague complaints

  31. 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

  32. 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

  33. Is thisdeliriumordementia?

  34. 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

  35. Delirium vs Dementia(classic exam question)

  36. Delirium - Making the DiagnosisConfusional Assessment Method (CAM) • Validated tool • Distinguishes delirium vs dementia • Based on DSM-IIIR • Sensitivity 94-100% • Specificity 90-95% • Gold Standard = Psychiatrist

  37. Dementia • Insidious onset – may be unrecognized • Usually brought by family following an acute change • ~40% of dementia admitted to hospital also has a delirium

  38. Dementias • Cortical Dementias • Alzheimer’s disease • >50% of all dementia • Insidious onset • Social skills maintained until advanced • Pick’s disease • Frontal lobe release

  39. 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

  40. 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 DementiaED Workup

  41. 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

  42. 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 Dementia vs pseudodementiaNB: Classic exam question

  43. 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”

  44. 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

  45. ?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 Case 6

  46. 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 Delirium vs Primary PsychosisNB: another classic exam question

  47. 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

  48. 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

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