Organic Mental Disorders

Question 1

Delirium

Answer 1

Acute, Generalised Impairment of Brain Function; Crucially, impaired
consciousness; Primary cause often outside of the brain

Question 2

Dementia

Answer 2

Chronic, Generalised Impairment; Main feature is Global Intellectual Impairment;
Might also involve changes in Mood and Behaviour
o Primary cause within brain e.g. Alzheimer’s Disease

Question 3

Specific Syndromes

Answer 3

Includes disorders with predominant impairment of Memory, Thinking,
Mood or Personality Change
o Includes Neurological disorders which frequently lead to Organic Psychiatric
complications e.g. Epilepsy

Question 4

Delirium Features

Answer 4

• Acute Impairment of Consciousness producing Generalised Cognitive Impairment; =Acute
Confusional State; 15% of patients on wards, with primary cause often systemic illness
• Impaired Consciousness most important (Deficit in Attention, Concentration, Awareness);
Often not able to follow/engage in logical conversation
o Fluctuates in intensity, often worse in the evening
• Disorientation, Overactive/Underactive Behaviour, Disturbed Sleep, Impaired thinking, Ideas
of Reference and Delusions, Labile, Disordered Mood
• Misinterpretations, Illusions and Visual Hallucinations; Tactile and Auditory Hallucinations
occur but are less frequent; Disturbances of Memory and Insight

Question 5

Delirium Epidemiology

Answer 5

Extremely common; May occur in all age groups; Those at Extremes of Age, Pre-existing
Dementia or Serious Physical Illness make up majority; More common with Primary Mood or
Anxiety Disorders; Half of Delirium occurs in people with underlying Dementia syndrome
o Highest incidence on Intensive Care (40 – 60%)

Question 6

Aetiology of Delirium

Answer 6

• Usually multifactorial; Each relevant at different points of illness
• Consistent clinical presentation suggests common pathological pathway for all aetiologies
• Diffuse slowing of EEG, global changes in Cerebral Circulation; Neuroimaging suggests
involvement of PFC, Thalamus, Post Parietal, Subcortical
o Unclear why Speech, Motor and Sensory intact in delirium while rest deranged
• Relative deficit in Cholinergic action compared to Excessive Dopaminergic Action

Question 7

Assessment of Delirium

Answer 7

• Aim to identify underlying physiological cause; Place in context with patient’s premorbid level
of Cognition and Functioning; Clinical Diagnosis, usually obvious on speaking to patient
• Collateral history valuable to identify course of illness; Medication History, Systems Review
and Full Neurological Examinations
• Bloods – FBC, U/Es, LFTs, TFTs, Ca, Phos, Mg, Glu, Lactate, Trop, Alb, Haematinics
• BC, U Dip and MC+S, ABG, ECG, CXR
• Consider further investigations – CT Head, LP, EEG if appropriate
• Quantify Delirium ≤6/10 on AMTS; MMSE < 25 (Although primarily for Dementia)

Question 8

Management of Delirium: Medical

Answer 8

Treat Underlying Cause – Oxygen requirement, Fluids, Antibiotics, Analgesia; Invasive
procedures and Intravenous access should only be done if valid indication
o Avoid unnecessary medications/ Polypharmacy

Question 9

Management of Delirium: Nursing

Answer 9

• Reassurance and Reorientation – Clock visible at all times; Constantly reminded of Time,
Place, Day and Date regularly
• Predictable, Consistent Routine – Nursed either Quiet side room, or near to Nursing Station;
Reasonably dark at night, light during day; Meals at standard times, Relatives and Friends
encouraged to stay or visit frequently

Question 10

Management of Delirium: Family

Answer 10

Explanation to Relatives and Friends – Allows them to help reassure and reorientate patient

Question 11

Management of Delirium: Sleep

Answer 11

Small dose of Hypnotics (Zopiclone 3.75mg nocte) or Benzodiazepines (Temazepam
10mg nocte); Avoid during daytime as sedative effects increase disorientation

Question 12

Management of Delirium: Disturbed/Violence/Distressed Behaviour

Answer 12

2/3rds of patient have clinical improvement on
Antipsychotics; Haloperidol, or Atypical Antipsychotics (E.g. Olanzapine)
o Lorazepam also effective but moderate risk of worsening the mental state
o IM dose might be required in acute setting, with follow-on oral therapy
o Should be regularly reviewed and never used unless other methods of management
have been exhausted

Question 13

Dementia

Answer 13

• Generalised decline of Intellect, Memory and Personality without Impairment of
Consciousness; Clinical syndrome caused by variety of pathologies
o Acquired disorder although onset might be any age; Onset before 65yrs = Presenile
o Increasing incidence, likely due to ageing population
• 25 million people worldwide; Increases dramatically as Life Expectancy increases further; Four
times more common in women

Question 14

Clinical Features of Dementia: Onset

Answer 14

• Insidious onset; might occur after acute deterioration; Might be trigged by social
circumstances or intercurrent illness; Might include uncharacteristic aggressive behaviour or
sexual disinhibition; Social lapses that are out of character

Question 15

Clinical Features of Dementia:Cognition

Answer 15

Decline in cognitive function, Increased Forgetfulness; Difficulty in new learning; Memory loss
more obvious for recent vs remote events; Might have Aphasia, Agnosia and Apraxia

Question 16

Clinical Features of Dementia: Behaviour

Answer 16

– Disorganised, Restless or Inappropriate; Loss of Initiative and Reduction of
Interests; When taxed beyond their restricted capabilities, might develop Catastrophic
Reaction (Sudden Tearfulness or Anger)

Question 17

Clinical Features of Dementia:Mood

Answer 17

– Anxiety, Irritability, Depression; Important to differentiate from Pseudodementia

Question 18

Clinical Features of Dementia Thinking

Answer 18

Slows; Impoverished thinking; Difficulty in abstract thinking, Impaired judgment
Grossly Fragmented and Incoherent Thought
o Persecutory and Paranoid Delusions
o Disturbed thinking becomes reflected in speech – Syntactical Errors and Nominal
Dysphasia; Eventually might utter only meaningless noises or become mute

• Perceptual Disturbances, Visual Hallucinations

Question 19

Clinical Features of Dementia : Insight

Answer 19

Lacking into the degree, and nature of disorder

Question 20

Depressive Pseudo-dementia

Answer 20

Poor Memory, Appears Intellectually Impaired because Poor
Concentration leads to Inadequate Registration
o Depressed Mood may lead to Slowness and Self-Neglect
o Depressed Mood precedes Memory issues; Memory impairment improves when
interest is aroused; Patient is retarded and unwilling to cooperate (C/f Dementia)

Question 21

Differential Diagnosis of Dementia

Answer 21

Differential also includes Psychotic disorders and Delirium
• In Older Patients, Dementia is caused by 55%
Alzheimer’s Dementia, 20% Vascular Dementia,
15% Lewy Body Dementia

Question 22

Alzheimer’s Dementia

Answer 22

• Significantly reduced brain area and size; Widened
Sulci, Enlarged Ventricles; Cell loss, Shrinkage of
Dendritic Tree, Proliferation of Astrocytes and
Gliosis
o Amyloid Plaques – Dense, Insoluble Beta-
Amyloid Peptide surrounded by Abnormal Neuritis, Filled with Highly Phosphorylated
Tau Protein
o Neurofibrillary Tangles – Helical Filaments
of Microtubule-associated Proteins (Tau) in
a Highly Phosphorylated state; Found
throughout Cortical and Subcortical Grey
• Plaques and Tangles initially occur in Hippocampi,
and spread more widely after; Occipital Lobe and
Cerebellum sparing; Neurones lost tend to be
primarily Cholinergic

Question 23

Alzheimer’s Dementia: Classical Presentation

Answer 23

Forgetfulness is often first symptom; Disorientation, Mood Variation,
Poor Sleep, Social Behavioural Declines and Self-Neglect (Although some can compensate)
• Personality Changes (Exaggeration of less-favourable Traits)
• Progression might involve Parietal Lobe Dysfunction – Dysphagia, Dyspraxia, Agnosia

Question 24

Alzheimer’s Dementia:Risk Factors

Answer 24

FH, Age, Genetic Mutation, Previous Head Injury, Down Syndrome,
Hypothyroidism, Parkinson’s Disease, Cardiovascular Disease, Lower Education and IQ

Question 25

Alzheimer’s Dementia: Prognosis

Answer 25

Death occurs usually within 5 – 8years after first signs of disease; Most Pneumonia

Question 26

Vascular Dementia

Answer 26

=Multi-infarct; Clinical syndrome can be caused by variety of Cerebrovascular Pathologies;
Associated with Ischaemia and Non-Ischaemic changes
o Both large and small blood vessels might be affected; Infarcts tend to be Bilateral and
Involve Full Thickness of White Matter
o Multiple Infarction and Ischaemic Lesions in the White Matter
o Atrophy of Old Infarcted Areas; Blood Flow changes in Unaffected Regions
o Entire brain is smaller and Ventricles expanded

Question 27

Vascular Dementia: Presentation

Answer 27

Presents in Late 60s – Early 70s; More sudden onset than Alzheimer’s; May present after
Stroke; Emotional and Personality Changes tend to happen earlier C/f Alzheimer’s

Question 28

Vascular Dementia: Symptoms

Answer 28

Symptoms characteristically Fluctuating; Episodes of confusion common, especially at night;
Depression is common; Fits, TIA or other signs of Cerebral Ischaemic might occur

Question 29

Vascular Dementia: Diagnosis

Answer 29

Diagnosis from Alzheimer’s difficult unless clear CVA history; Risk factors include CVS disease,
Smoking, FH, AF, DM, Coagulopathies, Carotid Disease

Question 30

Lewy Body Dementia

Answer 30

• Spherical, Neuronal Inclusion Bodies; Clinically can manifest as Parkinson’s Disease, Dementia
with Lewy Bodies, and Autonomic Failure, associated with Degeneration of Sympathetic
Neurones of the Spinal Cord
o Dense, Intracytoplasmic Inclusions made of Phosphorylated Neurofilament Proteins
associated Ubiquitin and Alpha-Synuclein
o Primarily in Basal Ganglia and later spread into Cortex; Neuronal Loss is Prominent
with slight reduction in Total Brain Volume
o Mixture of Lewy Bodies and Alzheimer’s-type Amyloid Plaques and Tangles

Question 31

Lewy Body Dementia Clinical Features

Answer 31

• Relative Sparing of Memory with Fluctuating Cognitive Ability and LOC is typical
• Parkinsonianism – Postural Instability, Shuffling Gait; Only 20% of Tremor
• Visual Hallucinations, Falls, Depression and Sleep Disorders

Question 32

Lewy Body Dementia Prognosis

Answer 32

Life Expectancy 4 – 10 years; Rate of Cognitive Decline like Alzheimer’s; Pronounced
Parkinsonism affects movement; Perceptual and Behavioural Disturbance can be severe in later stages with Antipsychotics, requiring Residential Care

Question 33

Lewy Body Dementia Treatment

Answer 33

Levodopa and Antiparkinsons medications for Parkinsonianism; Anticholinergics
avoided as they might increase Confusion and Visual Hallucination
o Atypical Antipsychotics should be used before Typical agents as higher risk of Neuroleptic Malignant Syndrome in LBD

Question 34

Assessment of Dementia

Answer 34

• Memory Assessment Clinics – Includes Detailed History Taking, which covers Collateral
History and Mood; Full Physical Examination
• Cognitive Testing – MMSE widely used, with high sensitivity and specificity
• FBC, U/Es, LFTs, TFTs, B12, Folate, Thiamine, Ca, Glucose
o Special Investigations E.g. HIV, Syphilis only if high clinical suspicion
• Imaging – CT/MR Head if suspicion of Organic Brain Disease up to late middle age, or if
suggestion of Focal Lesions >65yrs

Question 35

MANAGEMENT OF DEMENTIA

Answer 35

Aim to reduce disability and provide support; Where possible, care outside hospital, either
with relatives or Residential care; Admission if at risk of harm to themselves or others, or
Complex Physical or Psychiatric Co-morbidities
o Maintain remaining ability, Relieve Distressing Symptoms, Arrangement of Practical
Requirements and Support for Relatives/Carers

Question 36

MANAGEMENT OF DEMENTIA: Written Care Planning

Answer 36

Includes views on Residential Care, EOLC, Resus status; Input from
OT, PT and Dietician should be offered

Question 37

MANAGEMENT OF DEMENTIA: Psychoeducation

Answer 37

Symptoms, Course, Prognosis, Treatments, Support Groups, Financial and Legal Considerations, and further information

Question 38

MANAGEMENT OF DEMENTIA: Psychoeducation

Answer 38

Symptoms, Course, Prognosis, Treatments, Support Groups, Financial and
Legal Considerations, and further information

Question 39

MANAGEMENT OF DEMENTIA: Structured Group Cognitive Stimulation Programmes

Answer 39

Improve MMSE scores and QOL for

patients with mild-moderate Dementia in medium term

Question 40

MANAGEMENT OF DEMENTIA: Management of Agitation and Challenging Behaviour

Answer 40

Aromatherapy, Music/Dance, Animal-Assisted Therapy, Massage Therapy

Question 41

Pharmacotherapy for Dementia

Answer 41

Acetylcholinesterase Inhibitors (E.g. Donepezil, Galantamine, Rivastigmine) – Increase
Concentration and Duration of Acetylcholine in CNS; Evidence for moderate-severe
Dementia; For use if MMSE 10 – 20, or agitation not managed conservatively or with
Antipsychotics; Not recommended if non-Alzheimer’s Dementia
Benzodiazepines avoided, especially in the day; Same indications as Antipsychotics

Question 42

Memantine

Answer 42

Glutamine NMDAR Antagonist; Improves Cognition, Mood, Behaviour in moderate-severe Dementia

Question 43

Antipsychotics

Answer 43

Avoided whenever possible; Used for Severely Distressed or Agitation
causing Risk to Self and Others
o Avoid in mild-moderate Dementia due to risk of Cerebrovascular Events

Question 44

Cortical and Subcortical Dementia

Answer 44

• Controversial Distinction – Cortical (Alzheimer’s Pattern) or Subcortical (Parkinson’s)
• Cortical – Memory > Motor; Aphasia, Apraxia, Acalculia more common
• Subcortical – Motor prominent with less marked Memory issues; Dysarthria > Aphasia; Impaired Coordination with Abnormal Posture

Question 45

Psychiatric Manifestations of Head Injury

Answer 45

• Majority Head Injuries associated with RTA and ETOH; Peak age 15 – 24yrs, M>F
• Difficulty to predict likelihood of brain injury; Neuropsychiatric consequences variable in
terms of severity and symptoms

Question 46

Acute Phase of Head Injury (Hours to Days)

Answer 46

o Post-Traumatic Amnesia – Loss of Memory for the period of injury until normal
memory resumes; Amnesia >24hrs associated with higher risk of impairment
o Retrograde Amnesia – Loss of Memory for Distinct Period of time leading up
o Acute Post-Traumatic Delirium – Confusion, Anxiety, Mood Lability, Paranoia,
Hallucinations occurring soon after regaining consciousness

Question 47

Longer Term Psychiatric Syndromes

Answer 47

o Cognitive Impairment – Global Dementia, or Focal Deficits in Memory, Attention,
Concentration or Speech; Repetitive Trauma can lead to Progressive Deterioration in
Intellectual Function
o Personality Change – Often most serious complication; Particularly after Frontal Lobe
damage; Irritability, Loss of Spontaneity and Drive, Coarsening of Behaviour, Reduced Control of Aggressive Impulses
o Emotional – Post Concussional Syndrome of Interaction of Minor Brain Damage with Anxiety and Depression

Question 48

Psychiatric Manifestations of Head Injury: Specialist Rehabilitation

Answer 48

PT and graded increased in physical activity, Occupational Therapy,
Working around and minimising Disabilities in ADL and specific Cognitive Deficits
• Depression, Psychosis and Agitation treated as with standard guidelines

Question 49

Psychiatric Manifestations of Epilepsy

Answer 49

4× risk of Psychiatric Disorders; Wide variation depending in type of Epilepsy
o Due to Effects of Stigma and Social Restrictions, Behavioural Disturbance associated
with Seizures, Disorders between Seizures or Disorders due to cause of Epilepsy

Question 50

Psychiatric Manifestations of Epilepsy: Prodromal

Answer 50

Period of Tension, Irritability, Depression lasting hours to days
• Ictal – if Focal Onset type, may have Automatic Behaviours; If prolonged, may appear as
Abnormal Mental State, Abnormal Behaviours or Social Withdrawal

Question 51

Psychiatric Manifestations of Epilepsy: Postictal

Answer 51

Prolonged period of Confusion, Disorientation, Inattention, Agitation that usually lasts few hours; Psychosis might occur if severe Epilepsy

Question 52

Psychiatric Manifestations of Epilepsy: Between Seizures

Answer 52

Cognitive Dysfunction (Either due to Residual Abnormal Electrical Activity,
or Anti-Epileptic Medications), Personality Disorders (Which may occur due to Social, or
Organic causes), Depression, Anxiety, Suicide (5×) and DSH (7×) Sexual Dysfunction
o Chronic Interictal Psychosis (Uncontrolled Epilepsy >10yrs; Similar presentation to
Schizophrenia, treated with Antipsychotics
o Forensic – Although might be confounded by Lower IQ, Lower SES