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Organic Mental Disorder

Delirium and Dementia


Outline
• Introduction to organic mental illness
• Delirium
– Introduction
– Prevalence
– Etiology
– Signs and symptoms
– Diagnostic Criteria
– Management
Organic Psychosis
• An organic psychosis is an abnormal mental state
with a known physical cause characterized by an
altered perception of reality.

• American Psychiatric Association defines organic


psychosis/ organic brain syndrome as, “a mental
disorder characteristically resulting from diffuse
impairment of brain tissue function from
any cause.”
Suspect Organic if…
• First episode
• Sudden onset
• Older age of onset
• History of drug and alcohol use disorders
• Concurrent medical or neurological disorder
• Neurological signs or symptoms seizure
like
,impairment in consciousness, head injury, sensory or
motor disturbances
• Presence of confusion , disorientation
,memory impairment or soft neurological sign.
• Prominent visual or other non auditory hallucinations.
Types of Organic Mental disorders
• Delirium
• Dementia
• Organic amnestic syndrome
• Other organic mental disorders
Delirium
• Delirium is an acute, transient, usually reversible,
fluctuating disturbance in attention, cognition,
and consciousness level.

• A sudden and significant decline in mental


functioning not better accounted for by a
preexisting or evolving dementia

• Disturbance of consciousness with reduced ability


to focus, sustain, and shift attention.
Prevalence
• Delirium may occur at any age but is more common
among the elderly.

• At least 10% of elderly patients who are admitted to


the hospital have delirium; 15 to 50% experience
delirium at some time during hospitalization.

• Delirium is also common after surgery and among


nursing home residents and ICU patients.

• When delirium occurs in younger people, it is usually


due to drug use or a life-threatening systemic disorder.
Etiology
• I nfections
• W ithdrawal drug or alcohol
• A cute metabolic conditions
• T rauma
• C NS pathology
• H ypoxia
• D efficiencies, vitamins
• E ndocrinopathies
• A cute vascular conditions
• T oxins or drugs
• H eavy metals poisoning
Clinical features:
• Impairment of consciousness
• Appearance and behaviour: the patient looks unwell and
behaviour may be marked by agitation or hypoactivity,
• Mood is frequently labile, with perplexity, intermittent periods
of anxiety or depression,
• Speech: the patient may mumble and be incoherent.
• Perception: visual perception is the modality most often
affected. Illusions and misinterpretations are frequent.
• Cognition: there are abnormalities in all areas of cognitive
function. Memory registration, retention, and recall are all
affected.
• Orientation: in obvious cases, orientation in person, time, and
place will all be disturbed.
• Concentration is impaired
• Memory disturbances are seen, with impaired
registration (e.g. digit span), short-term recall (e.g.
name and address), and long-term recall (e.g.
current news items).
• Insight is usually impaired.
• The disturbance of sleep wake cycle most
commonly insomnia at night with day time
drowsiness
• Diurnal variation is marked usually with worsening
of symptoms in the evening and night (called sun
downing )
ICD 10 diagnostic criteria
• Impairment of the consciousness and attention (on a
continuum from clouding to coma, reduced ability to
direct
,focus ,sustain and shift attention )

• Global disturbance of cognition ( perceptual distortions:


illusions and hallucinations most often visual ; impairment
of abstract thinking and comprehension with or with out
transient delusions ,but typically with some degree of
incoherence ,impairment of immediate recall and of
recent memory but relatively intact remote memory
;disorientation for time as well as in more
severe cases for place and person.
• Psychomotor disturbances ( hypo or hyper activity and
unpredictable shifts from one to one another ;increased
reaction time increased or decreased flow of speech
and enhanced startle reactions )

• Disturbance of sleep wake cycle (insomnia or in severe cases


total sleep loss or reversal of the sleep wake cycle ;day time
drowsiness ,nocturnal worsening of symptoms ,disturbing
dream or nightmares which may continue as
hallucinations after awakening)

• Emotional disturbances .e.g. depression, anxiety or fear,


irritability ,euphoria ,apathy.

• The onset is usually rapid and the course diurnally


fluctuating and total duration of the condition much less than
6 months .
Physical and Laboratory Examination
• Physical examination reveals the cause of delirium

• Laboratory work up include CBC, electrolytes, thyroid


function tests, ECG , EEG ,chest x ray ,blood
,urine , and CSF cultures .

• EEG: It shows a generalized slowing of activity


Management :
• Addressing the underlying causes,
• Maintaining behavioural control,
• Preventing complications,
• Supporting functional needs
Interventions for Delirium

Pharmacological
Intervention

Nonpharmacological
Intervention
Nonpharmacologic Interventions

Physical Interventions:

Environmental Interventions:

Cognitive Interventions:

Psychologic Interventions:
Physical Intervention
• Initial interventions include general measures to support
cerebral function, such as intravenous hydration and
appropriate nourishment.

• Supplemental oxygen has been found to be highly effective


in patients who develop delirium with pneumonia.

• Physical restraints, once a mainstay in the treatment of


delirium, are now used only when all pharmacologic and
nonpharmacologic interventions have failed.
Environmental Intervention
• Environmental manipulations are directed toward
providing the right amount of stimulation for the
patient, encouraging sleep, maximizing the patient's
ability to perceive the environment accurately,
maintaining safety, and achieving familiarity and
consistency for the patient.
• Over stimulation should be avoided, because it
contributes to both confusion and insomnia
• Avoid understimulation too
• Sun downing can be lessened by leaving a radio on in
the patient's room
• visual hallucinations by controlled visual stimuli, auditory
hallucinations by music and other meaningful external sounds, and
olfactory hallucinations by the introduction of odors or scents
• adequate daytime lighting and a night light should be provided
• Hearing aids, eyeglasses and other devices that assist sensory
perception should be used whenever possible and should not be
put away during a delirious episode
• having family members stay with the patient. Family members
should also be encouraged to bring personal effects from home,
because some patients with delirium are greatly comforted by the
presence of familiar photographs or objects.
Cognitive Interventions:
• Reorientation
• place a clock and a calendar where the patient can
see them easily.
• should then be verbally reoriented to time and place
several times over the course of the day.
• Repetition is recommended to compensate
for memory impairment in the delirious
patient.
Psychologic Interventions:
• The delusions expressed by a patient should not be
directly disputed. Instead, alternative explanations of
events should be offered, and frequent reassurance
should be given.
Pharmacologic Interventions
• 100 mg of B1 IV for thiamine deficiency and IV fluids
for fluid and electrolyte imbalances

• Symptomatic management: as many patients are


agitated , emergency psychiatric treatments may be
needed. Small doses of benzodiazepines (lorazepam
or diazepam) or antipsychotics (haloperidol) may
be given orally or parenterally.
Patient Education
• Educating families and patients regarding the etiology
and course of disease is an important role for physicians.
• Educate the patient, family, and primary caregivers
about future risk factors.
• Families may worry that the patient has brain damage
or a permanent psychiatric illness. Providing
reassurance that delirium often is temporary and is the
result of a medical condition may be beneficial to both
patients and their families.
• Suggest that family members or friends visit the patient,
usually one at a time, and provide a calm and structured
environment. Encourage them to furnish some familiar
objects, such as photos or a favorite blanket, to help
reorient the patient and make the patient feel more
secure.
Nursing management :
• Assessment
• Client history : from the clients history ,nurses should
assess the following areas of concern.
• Type ,frequency, and severity of mood swings,
• Personality and behavioral changes
• Catastrophic emotional reactions
• Cognitive changes such as problems with attention
span ,thinking process ,problem –solving
• Language difficulties
• Orientation to person ,place, date and situation
• Appropriateness of social behavior
Physical assessment
Assessment should focus on two main areas
• Signs of damage to the nervous system
• Evidence of diseases of other organs
Nursing diagnoses and Intervention
• Arrange furniture and other items in the room to
accommodate clients disabilities
• Store frequently used items within easy access
• Do not keep bed in elevated position
• Assist the client with ambulation
• Keep a dim light on at night
• Frequently orient the client to place ,time and
situation
• Soft restraints may be required if client is very
disoriented and hyperactive
• Disturbed thought process and other s : see nsg
mgmt of schizophrenia
Dementia (Chronic Organic
Mental Disorder)
Introduction
• Dementia is not a specific disease. It is an
overall term that describes a wide range of
symptoms associated with a decline in
memory or other thinking skills severe enough
to reduce a person’s ability to perform
everyday activities.
• Dementia is a general loss of cognitive
abilities, including impairment of memory as
well as one or more of the following: aphasia,
apraxia, agnosia, or disturbed planning,
organizing, and abstract thinking abilities.
Types of Dementia
• Alzheimer's disease (AD):
• Vascular dementia
• Lewy body dementia:
• Frontotemporal dementia:
• HIV-associated dementia
• Huntington's disease:
Alzheimer's disease (AD):
• The exact cause of Alzheimer’s disease (AD)
is
unknown, but theories hav been
several proposed,
such as reduction e in
acetylcholine, the formation of plaq brai
ues factors.
tangles, serious head trauma, and genetic n
and
• Pathologic changes in the brain include atrophy,
enlarged ventricles, and the presence of
numerous neurofibrillary plaques and tangles.
• Definitive diagnosis is bybiopsy or
autopsy examinatio of brai tissue,
although n refinement ofn diagnostic
criteria and new diagnostic tools now
enable clinicians to use specific clinical
features to identify the disease at an
accuracy rate of 70% to 90%.
Vascular Dementia
• This type of dementia is caused by significant
cerebrovascular disease.
• The client suffers the equivalent of small
strokes caused by arterial hypertension or
cerebral emboli or thrombi, which destroy
many areas of the brain.
• The onset of symptoms is more abrupt than in
AD and runs a highly variable course, progressing
in steps rather than as a gradual deterioration.
Dementia due to HIV Disease
• The immune dysfunction associated with
human immunodeficiency virus (HIV) disease
can lead to brain infections by other organisms.
• HIV also appears to cause dementia directly.
Lewy body Dementia
• Clinically, Lewy body disease is fairly similar to
AD; however, it tends to progress more
rapidly, and there is an earlier appearance
visual hallucinations and parkinsonian
features.
• This disorder is distinctive by the presence of
Lewy bodies—eosinophilic inclusion bodies—
seen in the cerebral cortex and brainstem
Frontotemporal Dementia
• Frontotempora dementia (FTD)
l degeneration or
frontotemporal
group s caused by progressive
of disorders refers to a
nerve cell loss in the brain's frontal lobes (or
its temporal lobes.
• The cell damage caused
nerve
frontotemporal dementia leads to loss b
function in these brain regions, which variablyy
cause deterioration in behavior andof
personality, disturbances, or
language in muscle or motor functions.
alterations
• It was used to be called Picks disease.
Key Differences Between FTD and
Alzheimer's
• Age at diagnosis may be an important clue. Most
people with FTD are diagnosed in their 40s and
early 60s. Alzheimer's, on the other hand, grows
more common with increasing age.

• Memory loss tends to be a more prominent


symptom in early Alzheimer's than in early FTD,
although advanced FTD often causes memory
loss in addition to its more characteristic effects
on behavior and language.
• Behavior changes are the
noticeable symptoms often in first the
common form of FTD. Behavior
bvFTD, changes most
are
also common as Alzheimer's progresses, but
they tend to occur later in the disease.

• Hallucinations and delusions are relatively


common as Alzheimer's progresses, but
relatively uncommon in FTD.
• Problems with spatial orientation — for
example, getting lost in familiar places — are
more common in Alzheimer's than in FTD.

• Problems with speech. Although people with


Alzheimer's may have trouble thinking of the
right word or remembering names, they tend
to have less difficulty making sense when they
speak, understanding the speech of others, or
reading than those with FTD.
Huntington’s Dementia
• Huntington disease (HD) is a genetic,
autosomal dominant, neurodegenerative
disorder characterized clinically by disorders
of movement, progressive dementia, and
psychiatric and/or behavioral disturbance.
Dementia Due to Other General
Medical Conditions
• A number of other general medical conditions
can cause dementia.
• Some of these include endocrine conditions (e.g.,
hypoglycemia, hypothyroidism), pulmonary
disease, hepatic or renal failure, cardiopulmonary
insufficiency, fluid and electrolyte imbalances,
nutritional deficiencies, frontal or temporal lobe
lesions, central nervous system (CNS) or systemic
infections, uncontrolled epilepsy, and other
neurological conditions such as multiple sclerosis.
Substance-Induced Persisting
Dementia.
• This type of dementia is related to
persisting
the effects substances such
of alcohol, inhalants, as sedatives,
anxiolytics, other medications,
hypnotics, and
environmental toxins.
• The term “persisting” is used to indicate that
the dementia persists long after the effects of
substance intoxication or substance
withdrawal have subsided.
Causes of Dementia
• Degeneration of nerve cells
• Parkinson’s disease
• Huntington’s disease
• Infection like HIV, syphilis
• Toxic cause eg. Alcohol, carbon monoxide
• Trauma, stroke
Signs and symptoms of Dementia
• Memory losses.
• Impaired abstraction and planning
• Language and comprehension disturbances.
• Poor judgment.
• Impaired orientation ability
• Decreased attention and increased restlessness.
• Behavioral changes and psychosis.
• Wandering
• Personality Changes
• Impaired ability to perform motor activities
despite intact motor abilities (apraxia).

• Impairment in language ability, such as


difficulty naming objects. In some instances,
the individual may not speak at all (aphasia).
Additional symptoms
1.Emotional lability (marked variation in emotional
expression).
2.Catastrophic reaction (when confronted with an
assignment which is beyond the residual intellectual
capacity, patient may go into a sudden rage).
3.Thought abnormalities, e.g. perseveration,
delusions.
4.Urinary and faecal incontinence may develop in
later stages.
5.Neurological signs may or may not be present,
depending on the underlying cause.
Diagnosis
• Medical History
• Basic Medical Test
• Neurological Reflexes- reflexes, co-ordination
and balance, muscle tone and strength, eye
movement, speech and sensation.
• Brain imaging- EEG, CT, PECT
• Psychiatric Evaluation- Mental status
examination, mini mental status examination
Treatmen
t
• Pharmacological-
– cholinesterase inhibitors (amantadine),
– antidepressant (fluoxetine, Sertaline),
– anxiolytics (Lorazepam),
– antipsychotic (haloperidol, risperidone) etc.
according to need of patient.
Other Management
–Reduce environmental Confusion by-
• Approaching patient in pleasant and
calm way.
• Keep the environment simple and pleasing,
remove unwanted utensils and furniture.
• Maintain regular daily living schedule.
• Provide memory device like – list of
activities, reminding notes, label on items
etc.
• Increased environment cues
– Address patient by name to facilitate
orientation of self.
– Offer environmental cues to offer
orientation of time, place and person.
• Monitor medication regimen
– Administer drug at appropriate time and dose,
should not leave the medicine by patient’s side.
• Monitor temperature of food
– Patient is protected from burning self by warm
food.
– Assist in self care activities of patient
as required.
– Provide adequate rest and sleep
– Encourage visit from family and friends.
– Provide assistive device like glass, hearing
aid, walker etc. if needed.
– Caring a dementic patient is a burdensome
task for family members too, provide
support to the career too.
• Reminiscence Therapy
– Reminiscence therapy is defined by the American
Psychological ) as "the use of life histories –
written, oral, or both – to improve psychological
well-being.

– This form of therapeutic intervention respects the


life and experiences of the individual with the aim
to help the patient maintain good mental health.
• People with dementia often have difficulty
remembering what’s recently happened
in their lives.
• This can leave them feeling confused,
vulnerable and less confident.
• However, their memories from years ago often
remain detailed and intact.
Nursing Management
• Nursing Assessment
– Assess the key areas in history, MSE and MMSE to
get probable symptoms and defect.
Nursing Diagnosis
• Risk for trauma
• Risk for self directed or Other directed
violence
• Chronic Confusion
• Self Care Deficit
• Disturbed Sensory Perception
• Low self Esteem
• Care giver role strain
Expected Outcome
Nursing Intervention
• Assess client’s level of disorientation and confusion
to determine specifi c requirements for safety.
• Institute appropriate safety measures, such as the
following:
a.Place furniture in room in an arrangement that
best accommodates client’s disabilities.
b.Observe client behaviors frequently; assign staff on
one to- one basis if condition warrants; accompany
and assist client when ambulating; use wheelchair for
transporting long distances.
c.Store items that client uses frequently within easy
access.
d.Remove potentially harmful articles from client’s
room: cigarettes, matches, lighters, sharp objects.
e. Remain with client while he or she smokes.
f.Pad side rails and headboard of client with seizure
disorder. Institute seizure precautions as described
in procedure manual of individual institution.
g.If client is prone to wander, provide an area
within which wandering can be carried out safely.
• Frequently orient client to reality and
surroundings.
• Use tranquilizing medications and
restraints, as prescribed by physician, soft
client’s protection during periods of excessive
for
hyperactivity.
For decreasing violence
• Assess client’s level of anxiety and behaviors
that indicate the anxiety is increasing.
• Maintain low level of stimuli in client’s
environment (low lighting, few people, simple
decor, low noise level).
• Remove all potentially dangerous objects from
client’s environment.
• Have sufficient staff available to execute a
physical confrontation, if necessary.
• Use tranquilizing medications and soft
restraints, as prescribed by physician.

• Sit with client and provide one-to-one


observation if assessed to be actively suicidal.