1. ORGANIC MENTAL DISORDERS Maria L.A. Tiamson, MD Asst. Professor, Psychiatry New York Medical College

2. Delirium Delirium Dementia Dementia Amnestic Disorders Amnestic Disorders Subcategories: Subcategories:  caused by general medical condition, substance use or NOS Common Primary Symptom: cognitive impairment Common Primary Symptom: cognitive impairment DSM-IV

3. DELIRIUM CORE SYMPTOM: impairment of consciousness, ie. reduced ability to focus, sustain or shift attention CORE SYMPTOM: impairment of consciousness, ie. reduced ability to focus, sustain or shift attention acute onset and fluctuates acute onset and fluctuates direct physiologic consequences of a general medical condition direct physiologic consequences of a general medical condition a MEDICAL EMERGENCY !!! a MEDICAL EMERGENCY !!!

4. Epidemiology of Delirium 15-18% of med-surg 15-18% of med-surg 30% of post-CABG 30% of post-CABG 50% of post-hip surgery 50% of post-hip surgery frequently misdiagnosed frequently misdiagnosed

5. Risk Factors of Delirium extremes of age (old & young) extremes of age (old & young) burns (3rd degree) burns (3rd degree) post-cardiotomy patients post-cardiotomy patients drug dependence drug dependence HIV/AIDS HIV/AIDS pre-existing brain damage pre-existing brain damage history of delirium history of delirium

6. URGENT Diagnosis Withdrawal/Wernicke’s Withdrawal/Wernicke’s Hypertensive encephalopathy Hypertensive encephalopathy Hypoglycemia Hypoglycemia Hypoperfusion of CNS Hypoperfusion of CNS Hypoxemia Hypoxemia Intracranial bleed Intracranial bleed Meningitis/encephalitis Meningitis/encephalitis Poisons/Medications Poisons/Medications

8. Clinical Features of Delirium Prodrome Prodrome Temporal course Temporal course Attentional deficits and arousal Attentional deficits and arousal Orientation Orientation Language and cognition Language and cognition Perception Perception Mood Mood Other symptoms Other symptoms

9. Clinical Course of Delirium Diagnosis: rating scales, bedside exam, labs and other diagnostic tests, review of medications (including OTC drugs and illicit drugs Diagnosis: rating scales, bedside exam, labs and other diagnostic tests, review of medications (including OTC drugs and illicit drugs Course Course Prognosis Prognosis

10. Mini-mental Status Exam Orientation Orientation Registration Registration Attention and Calculation Attention and Calculation Recall Recall Language Language

13. Pathophysiology of Delirium Areas of the brain affected: Areas of the brain affected:  prefrontal cortex, right cerebral hemisphere, subcortical nuclei Neurotansmitters affected: Neurotansmitters affected:  acetylcholine  dopamine  GABA  histamine

14. Treatment of Delirium Etiological: VERY IMPORTANT Etiological: VERY IMPORTANT Symptomatic: Symptomatic:  neuroleptics  benzodiazepines

15. DEMENTIA Syndrome of acquired persistent impairment in intellectual function: memory, language, visuospatial skills, emotion or personality, and cognition Syndrome of acquired persistent impairment in intellectual function: memory, language, visuospatial skills, emotion or personality, and cognition Effect of pathological processes on the brain, NOT THE EFFECT OF AGING Effect of pathological processes on the brain, NOT THE EFFECT OF AGING

16. Epidemiology of Dementia 4 million severe dementia 4 million severe dementia 1-5 million mild to moderate 1-5 million mild to moderate 50-60% Alzheimer’s dementia 50-60% Alzheimer’s dementia 15-30% Vascular dementia 15-30% Vascular dementia 1-5% Other causes 1-5% Other causes 15% are reversible 15% are reversible

17. Classification of Dementia CORTICAL: Alzheimer’s CORTICAL: Alzheimer’s SUBCORTICAL: HAD, Parkinson’s, Huntington’s SUBCORTICAL: HAD, Parkinson’s, Huntington’s MIXED: Vascular MIXED: Vascular Pseudodementia Pseudodementia

18. Risk Factors for Dementia ALZHEIMER’S: ALZHEIMER’S:  female, hx of 1st degree relative with AD, hx of Down’s, hx of head trauma MULTI-INFARCT DEMENTIA (Vascular): MULTI-INFARCT DEMENTIA (Vascular):  male, HTN, 60-70 y/o H.A.D.: H.A.D.:  wasting syndrome, older age at dx, substance abuse hx

19. Clinical Features of Dementia Memory Memory Orientation Orientation Language changes Language changes Personality changes Personality changes Perceptual changes Perceptual changes Other symptoms Other symptoms

20. Cortical Dementias Amnesia Amnesia Apraxia Apraxia Aphasia Aphasia Agnosia Agnosia diffuse atrophy with flattened sulci anf enlarged ventricles diffuse atrophy with flattened sulci anf enlarged ventricles senile amyloid plaques, neurofibrillary tangles senile amyloid plaques, neurofibrillary tangles

21. Vascular Dementias Stepwise deterioration of functioning Stepwise deterioration of functioning affects small and medium sized cerebral vessels affects small and medium sized cerebral vessels multiple parenchymal lesions spread over wide areas of the brain multiple parenchymal lesions spread over wide areas of the brain

22. Subcortical Dementia Apathy, depression, psychomotor retardation Apathy, depression, psychomotor retardation affects frontal lobe, basal ganglia, thalamus affects frontal lobe, basal ganglia, thalamus disruption of fundamental cerebral functions: arousal, attention, motivation and rate of information processing disruption of fundamental cerebral functions: arousal, attention, motivation and rate of information processing

23. Pseudodementia Dementia syndrome of depression Dementia syndrome of depression “don’t know” answers typical “don’t know” answers typical attention and concentration well preserved attention and concentration well preserved indifference to cognitive impairment indifference to cognitive impairment

24. Treatment of Dementia Etiologic: Etiologic:  cholinesterase inhibitors: tacrine, donepezil, revastigmine, metrifonate  HAART Treatment of co-morbid conditions: Treatment of co-morbid conditions:  depression, agitation, psychosis Adjunctive treatments: Adjunctive treatments:  vit.E, hydergine, selegeline, ginkgo biloba

25. Treatment of Dementia Supportive treatment Supportive treatment  creating a safe environment Psychotherapy Psychotherapy Legal issues Legal issues

27. Amnestic Disorders Single symptom of a memory disturbance that causes significant impairment in functioning Single symptom of a memory disturbance that causes significant impairment in functioning anterograde amnesia anterograde amnesia retrograde amnesia retrograde amnesia

28. Major Causes of Amnesia Systemic medical conditions Systemic medical conditions Primary brain conditions Primary brain conditions Substance related causes Substance related causes Affects dorsomedial and midline thalamic nuclei, hippocampus, mammilary bodies, amygdala Affects dorsomedial and midline thalamic nuclei, hippocampus, mammilary bodies, amygdala

29. Treatment of Amnesia Etiological Etiological Psychotherapy Psychotherapy