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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 l.jpg

Organic Brain Syndromes

Aric Storck

Resident Rounds

February 16, 2005


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Objectives

  • Approach to organic brain syndromes

  • Delirium vs dementia

  • OBS vs Psych

  • Common presentations

  • Will not discuss treatment

  • Not evidence based


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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


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definitions continued …

  • Acute Organic Brain Syndrome

    • Delirium

  • Chronic Organic Brain Syndrome

    • Dementia


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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


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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


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DDx

Top three?

OBS vs Functional?

Management

CT head ?

Labs ?

Haldol ?

Crisis Team to see ?

Long term placement ?

What is your approach?


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Differential Diagnosis

  • I WATCH DEATH

    • Infectious

    • Withdrawal

    • Acute Metabolic

    • Trauma

    • CNS disease

    • Hypoxia/hypercarbia

    • Deficiencies

    • Environmental/Endocrine

    • Acute Vascular

    • Toxins/Drugs

    • Heavy Metal


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DDxInfectious

  • Systemic

    • Urinary Tract Infection

    • Sepsis

  • Primary CNS

    • Encephalitis

    • Meningitis

    • Central Nervous System Abscess


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DDxWithdrawal

  • Sedative Hypnotics

    • Alcohol

    • Benzodiazepines

    • Barbituates


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DDxAcute Metabolic

  • Acidosis

  • ↑ or ↓ glucose

  • ↑ or ↓ Na

  • ↑ Ca

  • ↓ Mg

  • Renal failure

  • Hepatic failure


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DDxTrauma

  • Head trauma

  • Burns


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DDxCNS Disease

  • Bleeds

    • SAH, EPH, SDH, ICH

  • CVA

  • Increased ICP

  • Tumor

  • Seizure

  • Vasculitis

  • Degenerative


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DDxHypoxia & Hypercarbia

  • COPD

  • Pneumonia

  • CO

    • Winter, >1 individual

  • Methemoglobinemia


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DDxDeficiencies

  • B12

  • Thiamine

    • Wernicke’s

  • Niacin


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DDxEnvironmental / Endocrine

  • Hypothermia

  • Hyperthermia

  • Hypothyroid

  • DKA / HONK


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DDxAcute Vascular

  • Hypertensive encephalopathy

  • Intracranial bleed

  • Cerebral vein thrombosis


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DDxToxins/Drugs

  • Medications

    • Anticholinergics

    • Diuretics

    • Lithium

  • Drugs of Abuse

    • EtOH

    • Street drugs


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DDxHeavy Metals

  • Mercury

    • “Mad as a hatter….”

  • Lead


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Case 2

  • 67M

    • Progressively confused and lethargic x 2 days

    • Heavy smoker

      • Takes orange, green, blue puffers

    • Has runny nose, cough, chills


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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…


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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


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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


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Criteria for DeliriumDSM - IV

  • Disturbance of consciousness

  • Change in cognition

    • Memory deficit, disorientation, perceptual disturbance

  • Develops over short period

    • May fluctuate


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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


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Case 3

  • O/E 115 38 91/54 38.7 94%

  • Disoriented & agitated

  • Diaphoretic

  • Breathing very deeply

  • ABG 7.51 / 11 / 134 / 11


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Infectious

Withdrawal

Acute Metabolic

Trauma

CNS disease

Hypoxia / hypercarbia

Deficiencies

Environmental / Endocrine

Acute Vascular

Toxins/Drugs

Heavy Metal

I WATCH DEATH


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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


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Case 4

  • 82F – from a lodge

    • Not answering telephone

    • Lethargic

    • Unable to walk

    • Not coming to meals

    • No fever / cough / dysuria / pain


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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


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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


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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


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Is thisdeliriumordementia?


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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


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Delirium vs Dementia(classic exam question)


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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


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Dementia

  • Insidious onset – may be unrecognized

  • Usually brought by family following an acute change

  • ~40% of dementia admitted to hospital also has a delirium


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Dementias

  • Cortical Dementias

    • Alzheimer’s disease

      • >50% of all dementia

      • Insidious onset

      • Social skills maintained until advanced

    • Pick’s disease

      • Frontal lobe release


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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


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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


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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


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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


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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”


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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


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?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


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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


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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


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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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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

Case 7


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Syndromes with altered mentation and hypertonia

  • Serotonin syndrome

  • Malignant hyperthermia

  • Neuroleptic malignant syndrome

  • thyrotoxicosis

  • heatstroke

  • CNS hemorrhage

  • tetanus

EMR March 1999


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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)


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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


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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?


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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

What’s going on?


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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


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Case 9

  • O/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?


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Case 9


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Delirium on Dementia

  • Common

  • Difficult to sort out what’s new

  • Precipitating events

    • Pain

      • ischemic gut, AMI, AAA

    • Dehydration

    • Infection

      • UTI

      • Pneumonia


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The end


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Meds that cause delirium


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Folstein Mini-Mental Status Examination


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Folstein MMSE

  • ACEP guidelines

    • Advocate using in altered mental status

  • Passing grade 24/30

  • Screening tool – non-specific


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