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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) 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 definitions continued … Acute Organic Brain Syndrome – Delirium Chronic Organic Brain Syndrome – Dementia 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 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 What is your approach? DDx – Top three? OBS vs Functional? Management – – – – – CT head ? Labs ? Haldol ? Crisis Team to see ? Long term placement ? Differential Diagnosis I WATCH DEATH – – – – – – – – – – – Infectious Withdrawal Acute Metabolic Trauma CNS disease Hypoxia/hypercarbia Deficiencies Environmental/Endocrine Acute Vascular Toxins/Drugs Heavy Metal DDx Infectious Systemic – Urinary Tract Infection – Sepsis Primary CNS – Encephalitis – Meningitis – Central Nervous System Abscess DDx Withdrawal Sedative Hypnotics – Alcohol – Benzodiazepines – Barbituates DDx Acute Metabolic Acidosis ↑ or ↓ glucose ↑ or ↓ Na ↑ Ca ↓ Mg Renal failure Hepatic failure DDx Trauma Head trauma Burns DDx CNS Disease Bleeds – SAH, EPH, SDH, ICH CVA Increased ICP Tumor Seizure Vasculitis Degenerative DDx Hypoxia & Hypercarbia COPD Pneumonia CO – Winter, >1 individual Methemoglobinemia DDx Deficiencies B12 Thiamine – Wernicke’s Niacin DDx Environmental / Endocrine Hypothermia Hyperthermia Hypothyroid DKA / HONK DDx Acute Vascular Hypertensive encephalopathy Intracranial bleed Cerebral vein thrombosis DDx Toxins/Drugs Medications – Anticholinergics – Diuretics – Lithium Drugs of Abuse – EtOH – Street drugs DDx Heavy Metals Mercury – “Mad as a hatter….” Lead Case 2 67M – Progressively confused and lethargic x 2 days – Heavy smoker • Takes orange, green, blue puffers – Has runny nose, cough, chills Case 2 – the confused smoker… 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… 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 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 Criteria for Delirium DSM - IV Disturbance of consciousness Change in cognition – Memory deficit, disorientation, perceptual disturbance Develops over short period – May fluctuate Back to Case 3 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 Case 3 O/E 115 38 91/54 38.7 94% Disoriented & agitated Diaphoretic Breathing very deeply ABG 7.51 / 11 / 134 / 11 I WATCH DEATH Infectious Withdrawal Acute Metabolic Trauma CNS disease Hypoxia / hypercarbia Deficiencies Environmental / Endocrine Acute Vascular Toxins/Drugs Heavy Metal 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 Case 4 82F – from a lodge – Not answering telephone – Lethargic – Unable to walk – Not coming to meals – No fever / cough / dysuria / pain Approach to elderly patient with vague complaints 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 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 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 Is this delirium or dementia? Diagnosis of Dementia DSM 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 Delirium vs Dementia (classic exam question) delirium dementia onset hours – days months – years LOC altered Usually normal Autonomic disturbances Frequent Infrequent orientation +/- +/- perception May be abnormal Usually normal course reversible Usually irreversible Delirium - Making the Diagnosis Confusional Assessment Method (CAM) – Validated tool – Distinguishes delirium vs dementia – Based on DSM-IIIR – Sensitivity 94-100% – Specificity 90-95% – Gold Standard = Psychiatrist Dementia Insidious onset – may be unrecognized Usually brought by family following an acute change ~40% of dementia admitted to hospital also has a delirium Dementias Cortical Dementias – Alzheimer’s disease • >50% of all dementia • Insidious onset • Social skills maintained until advanced – Pick’s disease • Frontal lobe release 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 Dementia ED Workup 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 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 Dementia vs pseudodementia NB: Classic exam question Dementia – Insidious onset – No psych history – Demeanor Pseudodementia – Subacute onset – Psych history – Demeanor • Unconcerned • Confabulates • Struggles at tasks • Distressed • Emphasizes deficits • Limits effort – Attention impaired – Cooperative – Recent>remote memory loss – Chronic progressive – Attention preserved – Poor effort – Recent & remote memory loss – Responds to treatment 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” 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 Case 6 ?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 Delirium vs Primary Psychosis NB: another classic exam question 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 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 Case 7 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 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 Syndromes with altered mentation and hypertonia Serotonin syndrome Malignant hyperthermia Neuroleptic malignant syndrome thyrotoxicosis heatstroke CNS hemorrhage tetanus EMR March 1999 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) 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 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? What’s going on? 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 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 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? Case 9 Delirium on Dementia Common Difficult to sort out what’s new Precipitating events – Pain • ischemic gut, AMI, AAA – Dehydration – Infection • UTI • Pneumonia The end Meds that cause delirium Folstein Mini-Mental Status Examination Folstein MMSE ACEP guidelines – Advocate using in altered mental status Passing grade 24/30 Screening tool – non-specific