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organic disorders Flashcards

1
Q

what is an organic mental disorder

A

mental disorders that are due to common, demonstratable aetiology in cerebral disease, brain injury or other insult leading to cerebral dysfunction

they are acquired and are different from functional mental illnesses

can be:
1y - direct effect on the brain
2y - systemic diseases that affect the brain in addition to other systems/organs

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2
Q

problems when defining organic mental illnesses

A

many (if not all) psychiatric disorders have an organic basis - sz, BPAD, melancholia

many mental disorders present w/ a mixture of mental and physical features

physical disorders also have an effect on psychological functioning

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3
Q

common features to organic mental disorders

A

cognitive - memory, intellect, learning

sensorium - consciousness, attention

mood - depression, elation, anxiety

psychotic - hallucinations, delusions

personality and behaviour disturbance

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4
Q

onset of organic mental disorders

A

any age

most tend to start in adult or later life

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5
Q

prognosis for organic mental disorders

A

some irreversible and progressive

some transient/respond to treatment

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6
Q

acute/sub-acute organic mental disorders - 3 examples

A

delirium

organic mood disorder

organic psychotic disorder

  • recently appearing state of mental impairment as a result of intoxication, drug OD, infection, pain etc
  • often temporary
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7
Q

3 examples of chronic organic mental disorders

A

dementia

amnesic syndrome

organic personality change

-

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8
Q

what can cause chronic organic mental disorders

A

chronic drug/alcohol dependence - due to their long lasting toxic efffects

vascular problems - strokes

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9
Q

management of organic mental disorders

A

varies depending on cause

key points:

  • correct diagnosis
  • medication not usually that useful (except acute)
  • MDT approach
  • management of environment
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10
Q

triad of symptoms in Wernicke’s encephalopathy

A

acute confusional state
ataxia
opthalmoplegia

nystagmus

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11
Q

what causes wenicke’s encephalopathy

A

relataed to acute thiamine deficiency (B1)

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12
Q

what is wernicke’s encephalopathy often confused with

A

delirium tremens

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13
Q

prognosis of wernicke’s encephalopathy

A

untreated acute phase lasts ~ 2wks
84% develop korsakoff psychosis
- 15% mortality in untreated pts

w/ treatment: confusional state and opthalmoplegia can resolve within days

nystagmus, neuropathy and ataxia may be prolonged or permanent

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14
Q

treatment of wernicke’s encephaloptahy

A

high potency parenteral B1 replacement
- 3-7 days, oral thiamine

avoid carb load until thiamine replacement completed

all pts w/ WE symptoms or at high risk: parenteral thiamine
other undergoing detox/under investigation should be commenced on oral thiamine

concurrent treatment for alcohol withdrawal

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15
Q

what characterises alcohol amnesic syndrome (Korsakoff’s psychosis)

A

marked impairment of anterograde memory (ability to learn new info)

disturbance of time sense

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16
Q

features of korsakoff’s psychosis

A

no clouding of consciousness, absence of defect in immediate recall or global impairment

variable degrees of cognitive impairment

personality changes, apathy, loss of initiative

confabulation in the early stage

can improve w/ prolonged abstinence

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17
Q

differential diagnosis for wernicke’s encephalopathy

A

hepatic encephalopathy

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18
Q

where is hepatic encephalopathy usually seen

A

advanced alcoholic liver disease

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19
Q

features of hepatic encephalopathy

A

general psychomotor retardation, drowsiness

flucutating levels of confusion

related to build up of toxic products e.g. ammonia

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20
Q

when does hepatic encephalopathy improve

A

if and as liver function improves§

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21
Q

what type of illness is alcohol related brain damage

A

part of a spectrum of alcohol relate medical disorders

not a specific diagnosis

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22
Q

what causes alcohol related brain damage

A

neurotoxic effects of alcohol

head injury

vitamin deficiencies

cerebrovascular disease

hypoxia

hypoglycaemia

seizures

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23
Q

how common is alcohol related brain damage

A

35% of alcohol dependent persons will exhibit post-mortem evidence

prevalence is increasing - increased awareness/increased prevalence

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24
Q

when does alcohol related brain damage present

A

women tend to present 40-50y/o
- usually a decade younger than men

trend towards people presenting earlier than in the past

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25
features of alcohol related brain damage
50-80% of heavy drinkers display cognitive impairment when sober impairment in short term memory, long term recall, new skill application, set-shifting ability visuospatial ability decline > language ability decline
26
features of alcohol related brain damage on imaging
cortical atrophy (mainly white matter loss) ventricular enlargement
27
when can alcohol related brain damage improve
may recover spontaneously w/ abstinence/greatly reduced drinking
28
adults w/ incapacity act when is a person unable to make a decision
a person is unable to make a decision for themselves if, due to mental disorder or inability to communicate because of physical disability, they are incapable of: ``` acting or making decisions or communicating decisions or understanding decisions or retaining the memory of decisions ```
29
what is dementia
syndrome characterised by global cognitive impairment which is chronic in nature
30
underlying pathology in dementia
variable usually, but not always progressive
31
what are the different types of dementia
``` alzheimer vascular mixed Lewy body frontotemporal due to other brain disorders - huntington's, head injury, parkinson's ```
32
difference between dementia and depressive pseudodementia
33
how common is steroid induced psychosis
mild-moderate psychiatric symptoms in 28% pts treated w/ steroids ~6% severe reaction
34
factors affecting severity of steroid induced psychosis
dosage related to incidence but not timing, duration or severity subsequent events not predicted by previous (or lack of previous) reaction
35
management of steroid induced psychosis
consider tapering steroids - might not be possible due to medical condition being treated consider antipsychotic/mood stabiliser
36
endocrine and metabolic disorders - presentation
wide variety of clinical presentations likely to 1st present to GP/general medicine but some conditions (hypothyroidism, addison's) may present 1st to psychiatry - risk of mistaken diagnosis
37
link between CNS and endocrine/metabolic issues
CNS requires stable biochemical and metabolic environment for proper functioning
38
how reversible are endocrine/metabolic presentations
psychiatric presentations may be reversible if detected
39
what is anti-NMDA receptor encephalities
AI disease that targets NMDA receptors - ionotropic glutamate receptor involved in synaptic plasticity and memory function
40
presentation of anti-NMDA receptor encephalitis
~1/2 associated w/ malignancy - typically ovarian teratoma in women often presents initially w/ psychiatric symptoms
41
management of anti-NMDA receptor encephalitis prognosis
immunotherapy and tumour resection if indicated - IVIg, plasmapheresis, rituximab prognosis w/ treatment generally good - can be longer lasting cognitive and neuropsychiatric symptoms in a minority
42
what is delirium
aetiologically non-specific syndrome ``` characterised by concurrent disturbances of: consciousness and attention perception thinking memory psychomotor behaviour emotion sleep-wake cycle ```
43
presenting features of delirium
``` impairment of consciousness and attention global disturbance of cognition psychomotor disturbances disturbance of sleep-wake cycle emotional disturbance ```
44
timing of presentation of delirium
rapid onset diurnally fluctuating duration <6mths
45
physical signs of delirium
due to underlying cause autonomic activation: tachycardia, hypertension, diaphoresis, dilated pupils, fever dysgraphia often evident
46
causes of delirium
medication druga buse withdrawal syndromes metabolic vitamin deficiencies endocrinopathies infections neurological toxins and industrial exposures other
47
medication causes of derlirum
anticholinergic drugs - atropine, TCAs, antipsychotics, anti-histamines, OTC hypnotics, anti-vertigo, anti-spasmodics sedative hypnotics - esp w/ long 1/2 life e.g. flurazepam decongestants anti-asthmatics other sympathomimetics cimetidine, digitalis, L-dopa, meperidine, methyldopa, glucocorticoids
48
drug abuse causes of delirium
amphetamines cocaine PCP hallucinogens inhaled drugs - glue, NO
49
withdrawal syndrome causes of delirium
alcohol benzodiazepines - esp alprazolam barbiturates other sedative hypnotics
50
metabolic causes of delirium
hepatic encephalopathy uraemia hypoglycaemia hypercalcaemia hypo/hypermagnesaemia porphyria
51
vitamin deficiency causes of delirium
thiamine - wernicke-korsakoff syndrome vit B12 nicotinic acid - pellagra
52
endocrinopathy causes of delirium
hypo/hyperthyroidism hypo/hyperparathyroidism cushings addisons hypopituitarism
53
infectious causes of delirium
any systemic infection in the elderly esp w/ co-existing dementing process meningitis, encephalitis, brain abscess, neurosyphilis AIDS encephalopathy
54
neurological causes of delirium
head injury - post-concussive syndromes, bleeds stroke hypertensive encephalopathy intracranial neoplasm - esp frontal and temporal complex partial status epilepticus post-ictal states
55
toxins and industrial exposure causes of delirium
CO carbon disulphide organic solvents heavy metals
56
other causes of delirium
SLE - lupus cerebritis cerebral vasculitis - temporal arteritis, periarteritis nodosa paraneoplastic syndromes - limbic encephalitis hyperviscosity syndromes
57
mechanism of delirium
pathophysiology unclear - GABAergic and cholinergic NT systems? - central cholinergic deficiency? - increased risk associated w/ GABA agonists and anticholinergic drugs - increased dopaminergic activity? - direct neurotoxic effect of inflammatory cytokines?
58
delirium vs dementia
59
delirium vs functional psychosis
60
implications of delirium
disruption of other pts and anxiety of clinical staff prolonged hospital stays increased risk of institutionalisation ~£13000 per admission
61
prognosis for delirium
fluctuating course gradual resolution of symptoms w/ effective treatment of underlying cause - may improve more quickly at home slower symptom resolution in the elderly often patchy amnesia for delirious period following recovery mortality may be a marker for subsequent dementia
62
mortality rates for delirium
20% die during this admission | up to 50% at 1yr
63
management of delirium
correct contributing factors (disorientation, dehydration, constipation, hypoxia, immobility/limited, infection, polypharmacy, pain, poor nutrition, sensory impairment, sleep disturbance) enviornmental and supportive measures - education of relatives and healthcare staff, safe environment, optimise stimulation, orientation medications
64
medications for management of delirium - things to remember
avoid sedation unless required to maintain safety (severely agitated or required to facilitate investigation/treatment) evidence base and guidelines don't support use of medications in delirium medications sometimes have to be used for acute distress and to maintain safety: antipsychotics, benzodiazepines, promethazine use single medication, start low and assess response - slow doses in frail elderly
65
cautions to take with medications in delirium
antipsychotics - lower seizure threshold, be cautious if suspected withdrawal case benzodiazepines - safer first choice (interact w/ fewer things), can prolong delirious episode promethazinde - can ultimately worsen delirium
66
drugs to use when managing delirium
ANTIPSYCHOTICS: - risperidone 0.5-1mg - quetiapine 25-50mg if IM required - consider olanzapine/aripiprazole avoid in withdrawal state unless pt well covered w/ benzodiazepines - lower seizure threshold BENZODIAZEPINES: can prolong delirium - lorazepam 0.5-1mg use in withdrawal states - diazepam/chlordiazepoxide, caution in liver failure PROMETHAZINE: - oral/IM 10-25mg - off licence use - caution: in elderly (anticholinergic effect), prolonged QTc, lower seizure threshold

Y3 - psychiatry (27 decks)

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