organic brain syndromes aric storck resident rounds february 16, 2005

Organic Brain Syndromes

Aric StorckResident RoundsFebruary 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 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

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

DDxInfectious

Systemic– Urinary Tract Infection– Sepsis

Primary CNS– Encephalitis– Meningitis– Central Nervous System Abscess

DDxWithdrawal

Sedative Hypnotics– Alcohol– Benzodiazepines– Barbituates

DDxAcute Metabolic

Acidosis ↑ or ↓ glucose ↑ or ↓ Na ↑ Ca ↓ Mg Renal failure Hepatic failure

DDxTrauma

Head trauma Burns

DDxCNS Disease

Bleeds– SAH, EPH, SDH, ICH

CVA Increased ICP Tumor Seizure Vasculitis Degenerative

DDxHypoxia & Hypercarbia

COPD Pneumonia CO

– Winter, >1 individual Methemoglobinemia

DDxDeficiencies

B12 Thiamine

– Wernicke’s Niacin

DDxEnvironmental / Endocrine

Hypothermia Hyperthermia Hypothyroid DKA / HONK

DDxAcute Vascular

Hypertensive encephalopathy Intracranial bleed Cerebral vein thrombosis

DDxToxins/Drugs

Medications– Anticholinergics– Diuretics– Lithium

Drugs of Abuse– EtOH– Street drugs

DDxHeavy 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

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 2 – the confused smoker…

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 DeliriumDSM - 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

deliriumor

dementia?

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

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

DementiaED 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 pseudodementiaNB: Classic exam question

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

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 PsychosisNB: 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 9O/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