ORGANIC DISORDERS

To give an introduction into organic mental or brain disorders

1. PREPARED & PRESENTED

BY

RICHARD OPOKU ASARE
COLLEGE OF NURSING, NTOTROSO
SCHOOL OF ALLIED HEALTH SCIENCES-UDS, TAMALE
ORGANIC DISORDERS
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2. INTRODUCTION
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An organic disorder is a disorder caused by a
known pathological condition. In general, any
disorder that is caused by a known pathological
condition of an organic structure may be
categorized as an organic disorder, or more
specifically, as an organic mental disorder, or a
psychological disorder. An example is delirium, a
disorder that is caused by a known physical
dysfunction of the brain.

3. INTRODUCTION – Cont’d
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An organic mental disorder is a dysfunction of the
brain that may be permanent or temporary.
Organic mental disorders may be caused by
inherited physiology, injury, or disease affecting
brain tissues, chemical or hormonal
abnormalities, exposure to toxic materials,
neurological impairment, or abnormal changes
associated with aging (Logsdon, 2011).

4. DELIRIUM
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5. Definitions
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It is a state of great mental confusion in which
consciousness is clouded, attention cannot be sustained
and the stream of thought and speech incoherent,
accompanied with illusions, hallucinations and delusions.

This is a state of mental confusion characterized by
relatively rapid onset of wide spread disorganization of
the higher mental processes caused by a generalised
disturbance in the brain metabolism. It may include
impaired perception, memory and thinking, and
abnormal psychomotor activity (Carson, et al., 1996).

6. Definition – cont’d
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It is a change of consciousness that occurs over a short period
of time (Morrison-Valfre, 2005).

Delirium is an acute organic mental disorder characterized
by impairment of consciousness, disorientation and
disturbances in perception and restlessness that develop over
a short period of time. This condition is reversible.

Note: Delirium can be life threatening and should be viewed as
an emergency. It is usually caused by an infection, and so the
underlying cause needs to be treated.

7. Other terms used to describe delirium
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Acute Organic Brain Syndrome

Acute Confusional State

Acute Brain Failure

Toxic Confusional State

Acute Organic Psychosis

Acute Brain Syndrome

8. Incidence
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Highest among the organic mental disorders
In the general hospitals, about 10% –20% of the medical-
surgical inpatients suffer delirium.
About 30% of the elderly or the geriatric patients suffer this
condition.
It also higher in post-operative patients.

Course and Prognosis
The onset is usually abrupt. The duration of an episode is
usually brief, lasting for about a week.

9. Aetiology/Causes
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Systemic infections, e.g., pneumonia, puerperal sepsis,
typhoid, septicaemia, peritonitis, etc.
High fever, e.g., high body temperature.
General disturbance in brain metabolism and other
intracranial infections, e.g., frontal lesions of the right
parietal lobe, neurosyphilis, meningitis, cerebral malaria,
encephalitis, etc.
Inadequate oxygenation of the brain or anoxia, e.g.,
congestive cardiac failure, pneumonia, pulmonary failure,
anaemia, etc.
Metabolic disturbance, e.g., uraemia, electrolyte
imbalance, etc.

10. Aetiology/Causes – Cont’d
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Neurological disorders, e.g., convulsions, seizures, etc.
Head trauma, e.g., injury to the head, etc.
Excessive alcohol use and/or withdrawal symptoms,
e.g., delirium tremens (also known as abstinence delirium).
Drug intoxication and/or withdrawal symptoms,
e.g., atropine, cocaine, bromides, withdrawal from opiates
and barbiturates, etc.
Vitamin deficiency, e.g., pellagra, nicotinamide
deficiency, thiamine deficiency, Wernicke’s encephalopathy,
etc.
Metal poisons, e.g., lead, manganese, mercury, carbon
monoxide, etc.

11. Mnemonic for causes of delirium
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A useful mnemonic for remembering possible causes of delirium is I
WATCH DEATH
I = Infection
W = Withdrawal (drug)
A = Acute metabolic
T = Traumatic injury
C = CNS lesion
D = Deficiency of vitamins
E = Endocrine
A = Acute vascular
T = Toxins (Including medications)
H = Heavy metals

12. Signs and Symptoms
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1.Physical symptoms
Headache
Malaise
Perspiration
Oversensitivity to noise
and light
Aches and pains
Pale flush face

2.Disturbance of the sleep
cycle
Insomnia or in severe cases
total sleep loss.
Daytime drowsiness
Worsening of symptoms at
night (nightmares) which
may lead to hallucinations
upon waking up.
Restlessness

13. Signs and Symptoms – Cont’d
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3.Disturbance of emotions
Anxiety
Apathy
Depression
Euphoria
Fear
Irritability
Aggression
Perplexity

4.Neurological symptoms
Urinary incontinence
Tremor
Asterixis
Nystagmus
Ataxia

14. Signs and Symptoms – Cont’d
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5.Psychomotor disturbance
Sluggish
Stuporose
Hyper/hypo-activity
Picking at the bed clothes
(flocculation)


6.Cognitive disturbance
Impairment of abstract
thinking and
comprehension
Disturbance in recent
memory

7.Attention impairment
•Very hard to focus and
sustain attention

15. Signs and Symptoms – Cont’d
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8.Disturbance in perception
Illusions
Hallucinations (mostly
frightening visual images)

9.Disturbance in orientation
Disorientation in all spheres
(i.e., time/day, person/people,
and environment/place or
situation)
Patient disturbed by irrelevant
environment stimuli

10.Disturbance in thinking
Delusion
Incoherent speech


11.Impairment of consciousness
Clouding of consciousness
ranging from drowsiness to
stupor and coma

16. Diagnosis
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History
Physical Assessment
Short period of onset
Laboratory investigations
State of sensorium, e.g., clouding of
consciousness, disorientation, memory loss, etc.

17. Treatment
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Treat the underlying cause of infection
immediately, if known.
Administer IV fluids to correct electrolyte
imbalances.
Give oxygen for hypoxia.
Correct thiamine deficiency by giving IV 100 mg
of Vitamin B
12.
Serve diazepam, lorazepam, haloperidol, or
chlorpromazine to treat psychotic symptoms.

18. Nursing Management
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Provide Safe Environment
Restrict environmental stimuli, such as reducing sound
volumes of radio and TV.
Keep unit calm.
Keep surroundings well illuminated or bright.
There should always be the presence of a familiar face by
the patient, reassuring and supporting him or her.
Protect patient from harming self and/or others as s/he
responds to hallucinations, illusions, and delusions.

19. Nursing Management
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Provide Safe Environment – Cont’d
Give chemical and/or mechanical restraint to deal with
agitation and aggression demonstrated by the client.
Arrange unit/room of patient in such a way to prevent
injuries.
Teach client to request assistance for activities, such as
getting out of bed, going to bathroom.
Promptly respond to client’s call for assistance.

20. Nursing Management
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Meet the Physical Needs of the Patient
Conduct physical assessment on the patient regularly.

Provide appropriate care by using the needed nursing
measures to reduce high fever, if present.
Maintain intake and output chart.
Take care of hygiene needs, such as grooming, oral and skin
care, etc.
Monitor vital signs and document as appropriate.
Keenly observe the patient for any sign of drowsiness and
sleep, as this may be an indication that he or she is slipping
into coma.

21. Nursing Management
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Alleviate Patient’s Fear and Anxiety
Remove any object(s) in the room that
seems to be a source of misinterpreted
perception.
Have the same nurse all the time by the
patient’s bed side, if possible.
Keep room well lighted, especially at night.

22. Nursing Management
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Manage client’s confusion
Speak to client in a calm manner in a clear, low voice;
use simple sentence.
Allow adequate time for client to understand sentences
and respond.
Allow client to make decisions as much as s/he is able.
Provide orienting verbal cues when talking with client.
Use supportive touch, if appropriate.

23. Nursing Management
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Facilitate Orientation
Constantly repeat and explain to the patient where s/he is,
what date, day, and time it is.
Have a calendar in the room and tell patient what day it is
always.
Have a clock in the room and inform him/her what time it
is, if s/he is not able to do so.
Always introduce self and others to the patient with their
names, if the patient misidentifies them.
When the acute stage is over, take patient out and introduce
him/her to others.

24. Nursing Management
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Pharmacologic Treatment
Low dose neuroleptics are the drugs of choice for
delirious clients.

25. DEMENTIA
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26. Definitions
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It is a progressive deterioration of brain
functioning occurring after the completion of
brain maturation in adolescence. It is
characterized by deficits in memory, thinking and
behaviour.
This is the medical diagnostic term that describes
an organic mental disorder characterized by a
cluster of cognitive impairment that are generally
of gradual onset and irreversible.

27. Definitions – Cont’d
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It is a diffused brain dysfunction characterized by a gradual
progressive and chronic deterioration of intellectual
functioning. Judgement, orientation, memory, affect or
emotional stability, cognition and attention are all affected
(Shives, 1994).
Dementia is a permanent loss of the function of the brain. It
has a gradual onset (i.e., week to years), has a progressive
course, with intact consciousness. The intellect, memory, and
the personality of the individual are severely affected. Mostly
it is irreversible. This condition normally affects the
elderly.

28. Other terms used to describe dementia
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Chronic Brain Syndrome


Chronic Organic Mental Disorder

29. Classification
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Primary dementias – are those in which the dementia
itself is the major sign of some organic brain disease not
directly related to any other organic illness, e.g.,
Alzheimer’s disease.

Secondary dementias – are caused by or related to
another disease or condition, such as HIV or a cerebral
trauma.

Note: Keep in mind that a person with dementia may also
become delirious.

30. Incidence
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It is estimated that over 5% of people over age 65 have
severe form of dementia.
12% of the elderly suffer from mild to moderate severe.
Prognosis for this disease is poor.

Characteristics
Memory impairment.
Cognitive defects such as impaired language abilities and
decreased intellectual functioning.
Decline in social and occupational functioning.

31. Types of Dementia
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According to DSM IV-TR, there are five types of dementia (APA,
2000). These are:
Dementia of the Alzheimer’s type.
Vascular Dementia.
Dementia due to other General Medical Condition.
Substance-Induced Persisting Dementia.
Dementia due to Multiple Aetiologies.
However, these types dementias could be grouped into two main
forms:
a)Senile dementia
b)Presenile dementia

32. Forms
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Senile Dementia: - the age range for this condition is
usually 60 years and above. It is a progressive deterioration
marked by disturbances of memory. Mental changes may be
profound. Memory may be poor, especially for recent events.
Impaired judgement, imagination, concentration and
attention are commonly present, as well as episodic
excitement, delirium, expression, delusions and
hallucinations. Physical stamina is diminished. Tremor,
physical and mental sluggishness, and rigidity are commonly
seen when the basal ganglia are significantly affected.
Parkinsonian gait and drooling posture may be apparent.

33. Forms – Cont’d
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In Senile Psychosis, the frontal lobe gradually shrinks
and the space previously occupied by them is filled
up with cerebrospinal fluid, scattered throughout the
brain, there is evidence of cortical damage. The
amount of cerebral atrophy varies from person to
person. In some the wearing process is more rapid
and devastating having been assisted perhaps by
overwork, worries, syphilis, alcohol and other toxic
substances. Additionally, much depends upon
hereditary factors.

34. Forms – Cont’d
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Presenile Dementia: - the age range for this condition is
about 40–50 years. It is a steadily progressive disease with
symptoms resembling those of senile dementia. It shows
itself insidiously. Lack of concentration, irritability, delusions
of suspicion and persecution with a gradual impairment of
memory occurs. Disorientation, emotional liability and
restlessness are found. Physically, aphasia, apraxia, paralyses,
stereotyped movements may also be present.

Futher reading:
Senile delirium
Senile Paranoid and Depressive States

35. Diagnosis
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History from a reliable family member
Mental status examination
Neurologic Test
Psychometric Testing
Positron Emission Tomography (PET) scan
EEG
CT scan
Autopsy

36. Causes
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Alzheimer’s disease
Huntington’s disease
Pick’s disease
Parkinson’s disease
Creutzfeldt-Jakob disease
Dietary deficiency, e.g.,
Vitamin B deficiency, etc.
Head trauma, e.g., repeated
head injury
Sexually transmitted
infections, e.g., HIV, AIDS,
syphilis, etc.
Intracranial infections, e.g., brain
abscess, meningitis, intracranial
tumours, space occupying lesions, etc.
Alcohol and other toxic substances,
e.g., inhalants, etc
Medications, e.g., sedatives, hypnotics,
anxiolytics, etc.
Neurological disorders, e.g., seizures,
etc.
Physical illnesses, e.g., fever,
dehydration, severe anaemia, etc.
Metabolic disturbance, e.g., electrolyte
imbalance, hypoglycaemia, etc.
Respiratory failure
Degenerative process, such as aging.

37. Clinical features
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Hallucinations – may be visual or auditory.
Delusions – may be in the form that something has been stolen;
after he has forgotten the exact environment he placed an item,
blaming close attendants for stealing it. Another delusion is
jealousy, where he accuses his spouse of having an affair.
Personality changes – lack of interest in day to day activities,
easy mental fatigability, self-centered, withdrawn, decreased self-
care.
Memory impairment – recent and short term memory is
critically affected.
Cognitive impairment – disorientation, poor judgement,
difficulty in abstract thinking and/or calculation, decreased
attention span, confabulation.

38. Clinical features – Cont’d
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Affective impairment – exaggerated mood swings, labile mood,
irritability, depression.
Behavioural impairment – neurotic/psychotic behaviour, changes in
sexual drives and activities, stereotyped behaviour.
Neurological impairment – aphasia, apraxia, agnosia, seizures,
headache.
Sundowner syndrome – drowsiness, confusion, ataxia; accidental falls
may occur at night when external stimuli such as light and interpersonal
orienting cues are diminished.
Catastrophic tendency – agitation, attempt to compensate for defects
by using strategies to avoid demonstrating failures in intellectual activities,
such as changing the subject, cracking jokes or diverting the conversation.

39. Other symptoms include
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Incontinence
Swallowing problems
Difficulty performing tasks that take some thought, but that used
to come easily, such as balancing a checkbook, playing games
(such as “oware”, ludo, bridge, etc), and learning new
information or routines.
Getting lost on familiar routes.
Language problems, such as trouble finding the name of familiar
objects.
Losing interest in things he/she previously enjoyed, flat mood.
Misplacing items.
Personality changes and loss of social skills, which can lead to
inappropriate behaviors.

40. Other symptoms – Cont’d
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Change in sleep patterns, often waking up at night.
Difficulty doing basic tasks, such as preparing meals, choosing proper
clothing, or driving.
Forgetting details about current events.
Forgetting events in his/her own life history, losing awareness of who
he/she is.
Having hallucinations, arguments, striking out, and violent behavior.
Having delusions, depression, agitation.
More difficulty reading or writing.
Poor judgment and loss of ability to recognize danger.
Using the wrong word, not pronouncing words correctly, speaking in
confusing sentences.
Withdrawing from social contact.

41. Patients with severe dementia may
also exhibit the following symptoms
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Difficulty performing basic activities of daily
living, such as eating, dressing, and bathing.
Difficulty recognizing family members.
Can no longer understand language.

42. Behavioural and psychologic symptoms
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Reduced inhibition of inappropriate behaviors (e.g., patients
may undress in public places)
Misinterpretation of visual and auditory cues (e.g., they may
resist treatment, which they perceive as an assault)
Impaired short-term memory (e.g., they repeatedly ask for
things already received)
Reduced ability or inability to express needs (e.g., they
wander because they are lonely, frightened, or looking for
something or someone)

43. Nursing Management
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Provide a Safe Environment
Make sure that lights are bright enough.
Keep matches, lighters, bleach, paints, etc. out of reach of
patient.
Arrange the surroundings to minimize hazards and to prevent
falls.
Supervise patient to take medications. Do not allow him to
take medications alone.
Promptly respond to client’s call for assistance.

44. Nursing Management – Cont’d
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Facilitate Adequate Rest and Sleep
Provide calm and quiet environment for sleep.
Keep patient clean and dry.
Provide regular exercises during the day like sitting in a chair,
walking, or other activities client can manage to improve
sleep.
Monitor sleep and elimination patterns.
Discourage day time napping to help sleep at night.

45. Nursing Management – Cont’d
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Establish Good Interpersonal relationship
Give clear, simple verbal instructions. Verbal communications
should not be hurried.
Ask questions that require ‘Yes’ or ‘No’ answers. These are
the best for the patient.
Always introduce self and others with names.
Address patient appropriately by his name and/or title.

46. Nursing Management – Cont’d
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Facilitate Adequate Hygiene Needs
Compliment and/or praise the patient when he looks good.
Encourage and help in cleaning teeth and bathing.
Attend to his grooming needs.
Check finger and toe nails regularly; cut them if they are
overgrown.
Remove the lock, if patient have problems with the lock on the
bathroom door.
Remind the patient to attend to nature’s call at regular intervals,
just leave the toilet door open, and leave a light at night to find the
way.
Assist patient with other activities of daily living.

47. Nursing Management – Cont’d
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Maintain Adequate Food and Fluid Intake
Serve well balanced diet with plenty of fibre, such as
vegetables, whole wheat, fruits, to prevent constipation.
Allow plenty of time for meals.
Inform patient which meal it is, and what is there to eat.
Do not serve food too hot or too cold.
If patient is on fluids, maintain adequate fluid balance chart.
Provide prompt assistance to eat and drink adequate amounts
of foods and drink.

48. Nursing Management – Cont’d
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Facilitate the Development of Socially Acceptable Behaviour
Decrease socially inappropriate behaviour by reinforcing
socially acceptable skills.
Avoid overcorrection.
Repeat necessary information.
Focus on the positive behaviours of the patient, rather than
dwelling on the mistakes and/or failures.
Give appropriate reward for positive behaviours shown by
patient.
Ignore unacceptable behaviour.

49. Nursing Management – Cont’d
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Facilitate Orientation
Orient patient to reality in order to decrease confusion.
Orient patient to time, place, and person, especially when
approaching.
Provide clock with large faces to aid in orientation to time.
Use calendar with large writings and a separate page for each
day.
Provide newspapers, magazines, and journals to stimulate
interest in current affairs.

50. Nursing Management – Cont’d
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Increase interest in surroundings
Allow patient to chat and play with old friends, to relive the
past.
Make sure that each day has activities of interest, if possible,
for the demented patient.
Go for a walk together, listening to music, watching an
entertainment program on TV, and/or talk about the
activities of the day.

51. Nursing Management – Cont’d
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Involve Family and the Community in the Treatment and
Rehabilitation Programs
Instruct patient to always carry an identity card with him, in
case he is lost and could not find his way back after roaming
about.
Offer emotional support to the patient and family.
Educate family on the disease process and how to deal with
the patient.
Refer family to agencies and support groups for people living
with dementia for legal and financial advice, and support,
where necessary.

52. Nursing Management – Cont’d
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Administer Prescribed Medications
Serve medications according to time and dosage to deal with
hallucinations and inappropriate outburst of the patient.
Antipsychotics, e.g., Olanzapine
Vitamins supplements
Zolpidem, for insomnia.
Antidepressants, for depression.
Tacrine, for memory deficits.
Enkephalins, to slow the disease process.


53. Other treatment approaches
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Avoiding antacids,
Avoiding the use of aluminum cooking utensils, and
Avoid aluminum-containing deodorants
NB: These help to decrease aluminum intake.

54. Differentiating Delirium from Dementia
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CHARACTERISTICS DELIRIUM DEMENTIA
Onset Acute/Abrupt/Rapid Insidious/Slow
Course Fluctuates Slow decline
Reversibility Reversible Irreversible
Attention Impaired Intact early; often impaired late
Memory Impaired (registration, recent, and
remote)
Impaired (recent and remote)
Consciousness Impaired, can fluctuate rapidly Normal until later stages
Sleep-wake cycle Disrupted Usually normal

55. Differentiating Delirium from Dementia
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CHARACTERISTICS DELIRIUM DEMENTIA
Duration Hours to weeks Months to years
Alertness Impaired Normal
Orientation Impaired Intact early; impaired late
Behaviour Agitated, withdrawn or depressed: or
combination
Intact early
Speech Incoherent, rapid/slowed Coherent; word-finding
problems
Thoughts/Thinking Disorganized, delusions Impoverished
Perceptions Hallucinations/illusions Usually intact early
Aetiology Usually immediate cause identified or
known
Usually no immediate cause

56. END OF PRESENTATION
THANK YOU
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