Introduction
Organic
mental disorders are behavioral or psychological disorders associated with
transient or permanent brain dysfunction and include only those mental and
behavioral disorders that are due to demonstrable cerebral disease or disorder
either primary or secondary.
The presence
of following features requires special attention in identifying organic mental
disorders:
• First episode
• Sudden onset
• Older age of onset
• History of drug and alcohol use
disorders
• Concurrent medical or neurological
disorder
• Neurological signs or symptoms like
seizure ,impairment in consciousness, head injury, sensory or motor
disturbances
• Presence of confusion , disorientation
,memory impairment or soft neurological sign.
• Prominent visual or other non auditory
hallucinations
The disorder can be subcategorized into the
following categories :
• Delirium
• Dementia
• Organic amnestic syndrome
• Other organic mental disorders
Definition
Delirium is
not a clinical entity but a symptom-complex of manifold etiology. Its presence
signifies acute cerebral insufficiency and often represents a medical and/or
psychiatric emergency.Though some forms of delirium have distinctive features,
the fundamental phenomena are common to all, with clouding of consciousness the
sine qua non. The condition has two major components: (1) the basic "acute
brain syndrome" and (2) associated release phenomena.Clinicians must first
make the vital differentiation between delirium and "functional"
mental disorder, then proceed with the elucidation of the underlying diagnosis
and the concurrent organization of symptomatic and etiologic treatment.Proper
treatment combines management of the acute brain syndrome with general and
specific procedures for control of the underlying condition. Dealing with the
symptom-complex itself involves the principles and practice of sedation,
hydration, and nutrition, nursing care and supportive measures. Provided the
basic organic condition is treatable, the prognosis today is usually good.
According to
DSM IV TR delirium is characterized by a disturbance of consciousness and a
change in cognition that develop rapidly over a period of time.
History:
In the
English literature delirium was applied to an organic brain syndrome with
impaired consciousness. In contrast, in France délire was originally used to
describe a primary disturbance of perception. In 1909 Bonhoeffer defined
delirium as a clinical pattern of acute brain failure. In the past it was known in different names
such as acute confusional state, acute brain syndrome, acute organic reaction ,
toxic psychosis, metabolic encephalopathies
.
Epidemiology:
Delirium is
a common problem in all health care settings, with a prevalence of 0.4% in
general population, 1.1% in general population aged >55 years, 9–30% in
general hospital admissions and 5–55% in elderly general hospital admissions.
Predisposing factors :
A. Metabolic causes:
• Hypoxia
• Hypoglycemia
• Hepatic encephalopathy, uremic
encephalopathy
• Cardiac failure ,cardiac arrhythmias
• Water and electrolyte imbalance(water
,Na+,K+, Mg ++,Ca++)
• Metabolic acidosis
• Fever, anemia, hypovolemic shock
B. Endocrine causes
• Hypo-hyper pitutairism
• Hypo-hyper –thyroidism
• Hypo-hyper –parathyroidism
• Hypo-hyper –adrenalism
C. Drugs (both ingestion and withdrawal
causes delirium) and poisons
• Digitalis ,quinidine
,anti-hypertensive’s
• Alcohol, sedatives ,hypnonitics
• Tri cyclic antidepressants and antipsychotics
• Anti convulsants –levo dopa
• Salicylates ,steroids
,pencillin,insulin
• Methyl alcohol ,heavy metals
D. Nutritional deficiencies
• Thiamin, niacin, pyridoxine ,folic
acid ,B12
E. Systemic
infections:
• Acute and chronic (e.g. septicemia,
pneumonia and endocarditis)
F.
Intracranial causes:
• Epilepsy
• Head injury, subarachnoid hemorrhage
,sub dural hematoma
• Intracranial infections e.g.
meningitis, encephalitis cerebral malaria
• Stroke ,hypertensive encephalopathy
• Focal lesions e.g. right parietal
lesions
G. Miscellaneous
• Post operative states
• Sleep deprivation
• Heat ,electricity and radiation
Possible
causes of delirium, can be described with
the well-known I WATCH DEATH mnemonic.
The DSM IV
TR differentiates between the disorders of delirium by their etiology ,although
they share a common symptom presentation . Categories of delirium includes :
• Delirium due to general medical
condition
• Substance induced delirium
• Substance intoxication delirium
• Substance withdrawal delirium
• Delirium due to multiple etiologies
1. Delirium
due to general medical condition : In this type the delirium is due to direct
result of the physiological consequences of a general medical condition. Such
conditions include systemic infections, metabolic disorders, fluid or
electrolyte imbalances, hepatic or renal disease ,thiamine deficiency, post
operative states, hypertensive encephalopathy, postictal states and sequelae of head trauma.
2. Substance
induced delirium: this disorder is
characterized by the symptoms of delirium
that are attributed to medication side effects or exposure to a toxin. The following medications are reported to
cause substance induced delirium : anesthetics, analgesics, antiasthamatic
drugs ,anticonvulsants ,antihistamines, antihypertensive, antimicrobials,
antiparkinsonian drugs immunosuppressive agents ,lithium ,muscle relaxants and
psychotropic medications .
3. Substance
induced delirium : Delirium may arise within minutes to hours after taking
relatively high dose of certain drugs such as cannabis ,cocaine and
hallucinogens .
4. Substance
withdrawal delirium: it occurs after
reduction or termination of sustained usually high dose use of certain
substances such as alcohol, sedatives, hypnotics or anxiolytics.
5. Delirium
due to multiple etiologies : It is associated with more than one cause. It may
be the result of combined effect of general medication ad substance use.
Clinical features:
Delirium is characterized by the
following features:
• Impairment of consciousness is the key
feature that separates delirium from most other psychiatric disorders. There is
a continuum between mild impairment of consciousness and near unconsciousness.
There is fluctuation in intensity, and symptoms are often worse at night. The
patient may be unmistakably drowsy, but milder states are easy to miss,
especially by those who are unfamiliar with the patient's normal intellectual
performance. They may be apparent only in reduced or slowed performance on
bedside cognitive testing. There is disorientation in time, place, and the
identity of other people.
• Appearance and behaviour: the patient
looks unwell and behaviour may be marked by agitation or hypoactivity, by a
fluctuation between these states, or by a mixture of them—for example, a drowsy
patient plucking aimlessly at the bedclothes.
• Mood is frequently labile, with
perplexity, intermittent periods of anxiety or depression, or occasionally of
other mood states such as elation and irritability. Usually, the mood states
have an empty and transitory quality.
• Speech: the patient may mumble and be
incoherent.
• Perception: visual perception is the
modality most often affected. Illusions and misinterpretations are frequent.
For example, a patient may become agitated and fearful, believing that a shadow
in a dark room is actually an attacker. Visual hallucinations also occur. The
small living creatures which may be seen in delirium tremens are the best-known
example. Auditory and tactile hallucinations also occur. Complex sensory
distortions, such as colours being experienced as tastes, would suggest
intoxication with hallucinogens.
• Cognition: there are abnormalities in
all areas of cognitive function. Memory registration, retention, and recall are
all affected. Mild cases may show their most pronounced abnormalities in slow
performance on tasks or in the wandering of attention away from the task at
hand.
• Orientation: in obvious cases,
orientation in person, time, and place will all be disturbed. Milder degrees of
disorientation will need to be interpreted in the context of the individual
patient. For example, it may be considered not abnormal for a person who has
been seriously ill in hospital for a long time to be unaware of the day of the
month.
• Concentration is impaired, for
example, on tests such as ‘serial sevens' or ‘days of the week backwards'.
• Memory disturbances are seen, with
impaired registration (e.g. digit span), short-term recall (e.g. name and
address), and long-term recall (e.g. current news items). After recovery from
the illness there is usually (but not always) amnesia for the illness.
• Insight is usually impaired. The
patient will have no understanding of why a psychiatric assessment has been
requested
• The disturbance of sleep wake cycle
most commonly insomnia at night with day time drowsiness
• Diurnal variation is marked usually
with worsening of symptoms in the evening and night (called sun downing )
Diagnosis
ICD 10 diagnostic criteria : According ICD 10 , for
definite diagnosis of delirium ,symptoms should be present in each one of the
following areas .
• Impairment of the consciousness and
attention (on a continuum from clouding to coma, reduced ability to direct
,focus ,sustain and shift attention )
• Global disturbance of cognition (
perceptual distortions: illusions and hallucinations most often visual ;
impairment of abstract thinking and comprehension with or with out transient
delusions ,but typically with some degree of incoherence ,impairment of
immediate recall and of recent memory
but relatively intact remote memory ;disorientation for time as well as in more severe cases for place and person.
• Psychomotor disturbances ( hypo or
hyper activity and unpredictable shifts from one to one another ;increased
reaction time increased or decreased flow of speech and enhanced startle
reactions )
• Disturbance of sleep walk cycle
(insomnia or in severe cases total sleep loss or reversal of the sleep walk
cycle ;day time drowsiness ,nocturnal worsening of symptoms ,disturbing dream
or nightmares which may continue as
hallucinations after awakening)
• Emotional disturbances .e.g.
depression, anxiety or fear, irritability ,euphoria ,apathy.
• The onset is usually rapid and the
course diurnally fluctuating and total duration of the condition much less than
6 months .
Differential
diagnosis of delirium
• Functional psychotic disorders can
mimic the positive features of delirium, such as hallucinations.
• Stupor due to severe depression or
mania can be mistaken for a diminished level of consciousness.
• Dementia
• Amnestic disorders, such as Korsakov's
syndrome, also occur in clear consciousness, but the cognitive deficits are
concentrated in short-term memory. Immediate recall (e.g. digit span) is normal
in amnestic disorders, and long-term memory is relatively preserved: both are
impaired in delirium.
• Sleep disorders (e.g. narcolepsy) and
various forms of epilepsy (e.g. the rare petit mal status epilepticus in
children) may also need to be excluded.
Physical and
laboratory examinations :
• A bedside mental status examination or
Mini Mental Status Examination or neurological signs can be used to document
the cognitive impairment and to provide a base line from which to measure the
patients clinical course .
• The Confusion Assessment Method is
also widely used because it is reliable, brief, and applicable to a variety of
settings
Confusion
Assessment Method
• Delirium diagnosed if (a) + (b) + one
of either (c) or (d):
• Acute onset and fluctuating course:
Evidence of an acute change in mental status from the patient's baseline that
changes in severity during the day
• Inattention: Patient has difficulty
focusing attention, e.g. is easily distractible or has difficulty keeping track
of conversation
• Disorganized thinking: Patient's
thinking is disorganized or incoherent, as evidenced by rambling or irrelevant
conversation and unclear or illogical flow of ideas
• Altered consciousness: A rating of a
patient's level of consciousness as other than alert (normal) i.e. vigilant or
hyper alert, lethargic or drowsy, stuporus
or comatose
• Physical examination reveals the cause
of delirium
• Laboratory work up include CBP,
electrolytes, thyroid function tests, ECG , EEG
,chest x ray ,blood ,urine , and CSF cultures .
• EEG:
It shows a generalized slowing of activity
Management :
Four key
steps in management of delirium are –
• Addressing the underlying causes,
• Maintaining behavioural control,
• Preventing complications,
• Supporting functional needs
The management strategies include both
nonpharmacologic and pharmacologic interventions.
Nonpharmacologic
Interventions
Physical Interventions:
• Initial interventions include general
measures to support cerebral function, such as intravenous hydration and
appropriate nourishment.
• Supplemental oxygen has been found to
be highly effective in patients who develop delirium with pneumonia.
• Physical restraints, once a mainstay
in the treatment of delirium, are now used only when all pharmacologic and
nonpharmacologic interventions have failed.
Environmental Interventions:
• The hospital environment is a
significant factor in the management of delirium. Environmental manipulations
are directed toward providing the right amount of stimulation for the patient,
encouraging sleep, maximizing the patient's ability to perceive the environment
accurately, maintaining safety, and achieving familiarity and consistency for
the patient.
• Over stimulation should be avoided,
because it contributes to both confusion and insomnia
• Under stimulation is probably a more
common problem and is perhaps equally injurious. Delirious patients who are
left alone without stimulation often withdraw and begin to respond more to
internal stimuli than external stimuli. In such situations, regular interaction
with hospital staff can be helpful. It is often appropriate to place the
delirious patient in a room close to the nursing station or other workstation
• Sun downing can be lessened by leaving
a radio on in the patient's room
• It has long been recognized that, in
certain cases, the hallucinations of delirium can be specifically treated:
visual hallucinations by controlled visual stimuli, auditory hallucinations by
music and other meaningful external sounds, and olfactory hallucinations by the
introduction of odors or scents
• To help the patient perceive the
environment accurately, adequate daytime lighting and a night light should be
provided
• Hearing aids, eyeglasses and other
devices that assist sensory perception should be used whenever possible and
should not be put away during a delirious episode
• One of the most helpful interventions
is having family members stay with the patient. Family members should also be
encouraged to bring personal effects from home, because some patients with
delirium are greatly comforted by the presence of familiar photographs or
objects.
Cognitive Interventions:
Reorientation
is one of the most easily accomplished cognitive interventions. The first step
is to place a clock and a calendar where the patient can see them easily. The
patient should then be verbally reoriented to time and place several times over
the course of the day. Repetition is recommended to compensate for memory
impairment in the delirious patient.
Psychologic Interventions:
The delusions
expressed by a patient should not be directly disputed. Instead, alternative
explanations of events should be offered, and frequent reassurance should be
given.
Pharmacologic Interventions
• 100 mg of B1 IV for thiamine
deficiency and IV fluids for fluid and electrolyte imbalances
• Symptomatic management: as many
patients are agitated , emergency psychiatric treatments may be needed. Small
doses of benzodiazepines (lorazepam or diazepam) or antipsychotics (haloperidol) may be given orally or parenterally.
Prognosis:
Resolution
of symptoms may take longer in patients with poor pre morbid cognitive
function, incorrect or incomplete diagnosis of contributing factors, and
structural brain diseases treated with large doses of psychoactive medications
prior to the onset of acute medical illness. For some patients, the cognitive
effects of delirium may resolve slowly or not at all.
Patient Education
• Educating families and patients
regarding the etiology and course of disease is an important role for physicians.
• Educate the patient, family, and
primary caregivers about future risk factors.
• Families may worry that the patient
has brain damage or a permanent psychiatric illness. Providing reassurance that
delirium often is temporary and is the result of a medical condition may be
beneficial to both patients and their families.
• Suggest that family members or friends
visit the patient, usually one at a time, and provide a calm and structured
environment. Encourage them to furnish some familiar objects, such as photos or
a favorite blanket, to help reorient the patient and make the patient feel more
secure.
Nursing management :
Assessment
• Client history : from the clients
history ,nurses should assess the following areas of concern.
• Type ,frequency, and severity of mood
swings,
• Personality and behavioral changes
• Catastrophic emotional reactions
• Cognitive changes such as problems
with attention span ,thinking process ,problem –solving
• Language difficulties
• Orientation to person ,place, date and
situation
• Appropriateness of social behavior
Physical
assessment :
Assessment
should focus on two main areas
• Signs of damage to the nervous system
• Evidence of diseases of other organs
Nursing diagnoses :
1. Risk for
trauma related to impairment in cognitive and psychomotor function
Outcome
criteria : Client will not experience injury
Interventions:
• Arrange furniture and other items in
the room to accommodate clients disabilities
• Store frequently used items within
easy access
• Do not keep bed in elevated position
• Assist the client with ambulation
• Keep a dim light on at night
• Frequently orient the client to place
,time and situation
• Soft restraints may be required if
client is very disoriented and hyperactive
2. Disturbed
thought process related to cerebral degeneration as evidenced by
disorientation, confusion, memory deficits
and inaccurate interpretation of the environment
Outcome
criteria: client will interpret the environment accurately and maintain reality
orientation to the best of his or her cognitive ability
Interventions:
• Frequently orient the client to
reality. Use clock and calendars with large numbers that are easy to read
• Notes and large bold signs may be used
as reminders
• Keep explanation simple
• Discourage rumination of delusional
thinking
• Talk about real people and real events
• Monitor for medication side effect
3. Self care
deficit related to disorientation ,confusion and memory deficits as evidenced
by inability to fulfill the ADL
Outcome
criteria: client will accomplish the ADLs to the best of his or her ability.
Unfulfilled activities may be kept by caregivers
Interventions:
• Identify the self care deficits and
provide assistance as required
• Provide guidance and assistance for
independent actions
• Provide a structured schedule of
activities that does not change from day to day
• Provide for consistency in assignment
of daily caregivers
• Perform ongoing assessment of clients
ability to fulfill nutritional needs ,ensure personal safety ,follow medication
regimen and communicate need for assistance with activities that she or he
cannot accomplish independently
• Involve the family members in the care
of the patient
Conclusion
Delirium or
acute confusional state is a transient global disorder of cognition. The
condition is a medical emergency associated with increased morbidity and
mortality rates. Early diagnosis and resolution of symptoms are correlated with
the most favorable outcomes. Therefore, it must be treated as a medical
emergency.
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7. The ICD 10
