Organic Disorders

Question 1

What is the key feature of delirium?

Answer 1

Impaired consciousness, attention and global cognition with onset over hours or days

Question 2

What are the clinical features of delirium?

Answer 2

These symptoms fluctuate over the course the day and tend to be worse at night. Patient may show signs of hyperactivity or lethargy.
-	Reduced level of consciousness 
-	Psychiatric symptoms 
o	Disorientation (time/place/person)
o	Inattention
o	Illusions/hallucinations 
o	Altered personality 
o	Mood disorders 
o	Speech disorders (slurred/aphasic error/chaotic pattern)
-	Lacking insight

Question 3

What are the possible CNS causes of delirium?

Answer 3

Stroke, abscess, tumour and subdural haematoma

Question 4

What are the possible drug related causes of delirium?

Answer 4

Withdrawal, anticholinergics, antiemetics, antipsychotics, corticosteroids, digoxin, L-dopa, TCAs, opioids and alcohol

Question 5

What are the possible endocrine cases of delirium?

Answer 5

Hyperparathyroidism and hyper/hypothyroidism

Question 6

What are the possible infection/injury causes of delirium?

Answer 6

Encephalitis, meningitis, pneumonia, sepsis, UTI, burns and hypothermia

Question 7

What are the possible metabolic causes of delirium?

Answer 7

acid-base disturbance, hepatic encephalopathy, uraemia, hypo/hyperglycaemia, electrolyte abnormalities and thiamine deficiency

Question 8

Describe the main differences between delirium and dementia?

Answer 8

Delirium
- sudden onset and fluctuating course over days to weeks 
- varying consciousness level
- impaired attention 
- psychomotor changes 
Dementia 
- gradual onset memory problems, slowly progressing over months to years
- consciousness unimpaired 
- attention preserved 
- normal

Question 9

What parts of a history are required when delirium suspected?

Answer 9

Collateral - assess if changes in mental status are recent and what their normal level of functioning is
Drug history - new additions or drugs with possible CNS side effects
Alcohol history

Question 10

How is delirium examined?

Answer 10

Mini-metal state examination - shows attention deficits
Confusion Assessment Method - states diagnostic features for delirium
Examine patient for potential infection sites or focal neurological signs

Question 11

What does the Confusion Assessment Method state the diagnostic features of delirium are?

Answer 11

Acute change in cognition which fluctuates during the day
Inattention
Disturbance of consciousness
Disorganised thinking

Question 12

How is delirium managed?

Answer 12

Treat underlying cause/remove aggravating drugs
Nurse patients in quiet, well-lit room with same staff in attendance.
Reassure and re-orientate the patient regularly
Ensure no avoidable sensory deficits (e.g. hearing aids, glasses)

Question 13

Can you use medication when managing delirium?

Answer 13

Acute agitation can be managed with haloperidol or lorazepam, however these should generally be avoided as the can worsen or prolong the delirium

Question 14

What is dementia?

Answer 14

Dementia is a progressive global decline in cognitive function, without the impairment of consciousness.

Question 15

What are the clinical features of dementia?

Answer 15

Memory loss – usually first to appear
- Normally short-term memory affected first, which can lead to confusion. This is because damage to brain tissue is not universal and affects some areas of memory more than others
Visuo-spatial problems – easily disorientated by unfamiliar surroundings
Emotional disturbance
Loss of normal social behaviour
Language problems – both understanding and naming objects
Concentration issues
Short attention span – unable to plan, organise or sequence activities
Behavioural changes
- Persecutory delusions, agitation, aggression and wandering
Variable mood
Poor sleep
Restlessness
Hallucinations
Apathy
Depression/euphoria – severe depression rare due to loss of insight

Question 16

What are the clinical features of late stage dementia?

Answer 16

May include self-neglect, change in personality, motor/sensory abnormalities and seizures.

Question 17

How is dementia diagnosed?

Answer 17

As the main symptom is confusion - diagnosis is usually clinical (helped by use of MMSE). However because the confusion is the only apparent symptom, many other tests are required to rule out differentials.
Almost a diagnosis of exclusion

Question 18

What blood tests are required for dementia diagnosis.

Answer 18

Vitamin deficiencies (folate, B12, thiamine)
TFTs
FBCs - anaemia
U&Es - renal failure
LFTs – carcinoma, cirrhosis, encephalopathy
Glucose
CRP/ESR – UTI common

Question 19

Differential diagnoses for dementia?

Answer 19

Vitamin deficiencies 
Anaemia
Renal failure 
Thyroid issues 
Liver carcinoma
Cirrhosis 
Encephalopathy 
UTI 
Alcohol abuse 
Substance misuse
Delusion
Dehydration 
Constipation 
Delirium 
Parkinson’s 
Syphilis

Question 20

What imaging is required for diagnosing dementia?

Answer 20

CT/MRI
- to exclude treatable SOL such as hydrocephalus, tumour (meningioma)
or subdural haematoma
- can also show global atrophy (sign of dementia)

Question 21

How is dementia managed (generally)?

Answer 21

No cure – management is to reduce rate of disease progression
Important to make a will and/or advanced directive if discovered early enough, before patient become to ill for one to be accepted by law
Good palliative care is required, walking frames, catheters, day care, holiday admissions and attendance allowance, electronic tagging and a lasting power of attorney can help families manage the patient. If families can’t manage, then long-stay institutional care may be needed
Muscle relaxation and massage (MMM) should be tried before medication in dementia cases

Question 22

How is Alzheimer’s Disease managed?

Answer 22

Drug treatment only commenced in those with MMSE >12 (mild/moderate dementia), due to side effects of the drugs. Drug therapies are controversial
Anti-cholinesterase drugs
- Inhibits cholesterases (increases cholinergic transmission within brain)
- Side effects include anorexia, nausea, vomiting, abdominal pain, insomnia, confusion, agitation and headache
- Delays cognitive impairment in 40% of patients, but about 3-6 months
NMDA receptor agonists
- Glutamate NMDA receptor inhibitor. Selectively binds, depending on voltage, so preventing excitotoxicity
- Can be given with anti-cholinesterase drugs
- These are usually more well tolerated than anti-cholinesterase drugs, but are less effective

Question 23

How is vascular dementia managed?

Answer 23

Prevention most important to reduce vascular risk factors
- Aspirin/warfarin therapy
- BP control
- Anticholinesterases and memantine (may have some benefit)
Supportive care is needed to ensure patients stay in familiar home environment as long as possible. Burden of care often falls to relatives
- Engaging in cognitively taxing activities later on in life can prevent against dementia
- Vitamin E