ORGANIC BRAIN SYNDROMES

 

ORGANIC BRAIN SYNDROMES

These are mental illnesses or conditions that result from diffuse impairment of brain tissue function from whatever cause.

These syndromes or cluster of diseases are subdivided into psychotic and non psychotic depending on the severity of the functional impairment of the brain. A patient who cannot meet the ordinary demands of life is considered psychotic.

Normally, acute brain disorders are reversible, whereas chronic brain disorders tend to have permanent or irreversible impairment.

CLASSIFICATIONS 

Patients with similar clinical manifestations may be classified differently, depending on the examiner's discipline, training and background.

 

When a physician is confronted with a patient who has a mental disturbance, may first attempt to decide whether the disturbance represents an organic impairment of brain function or a functional disturbance or both. Once he/she decides that the patient is indeed suffering from an organic disturbance, he may properly classify the disorders as some form of encephalopathy.  Only when satisfied that a focal disturbance of brain tissue function is absent can one properly use the term "Organic Brain Syndrome".

Therefore, Organic Brain Syndromes can be classified as follows:

 

 

 

1. ACUTE BRAIN SYNDROME 

 

This has four primary characteristics such as:

 

i)                 The onset is sudden with the rapid development of impairment of orientation, memory, intellectualfunction, judgement and affect or mood.

 

ii)               Delirium, stupour or coma may be present at times associated with the release of the underlying psychotic  and neurotic reactions.

 

iii)               The syndrome is caused temporarily, reversible, diffuse disturbance of brain function.

 

iv)              The clinical course, although usually brief, may persist for a month or longer, but it always ends with some  resolutions of the organic symptoms.

 

 

 

2. A Chronic Brain Syndrome

This has also four primary characteristics namely: 

 

i) Onset is often,but not always slow and insidious, taking several weeks or more and progressively impairing brain tissue function.

 

ii) The clinical expression is often described as a dementia, but sometimes delirium, stupour and coma supervene especially in advanced states. As with acute brain syndromes, the symptoms of organic  and functional impairment of brain function may coexist.

 

iii) The syndrome is caused by an irreversible, permanent diffuse alteration of the brain function.

 

iv) The clinical course usually progresses over months or years and the syndrome may end in death. Although the responsible agent is identified and removed, some permanent alterations in brain function remains.

 

 

The varieties of Organic Brain Syndromes (OBS) are:

 

a) DELIRIUM

 

This is a mental state in which there is impairment of consciousness, resulting in reduced levels of alertness, attention and perception of the environment.

 

 

ETIOLOGY

 

- Drugs such as: digoxin, diuretics, alcoholic intoxication and withdrawal, steroids etc.

 

- Infections: Cerebral malaria, meningitis, HIV/AIDS, PUD, UTI, Septicaemia etc. 

 

- Diseases: Diabetes Mellitus, renal syndromes, rheumatic heart disease, hepatic etc.

- Hypo/hyperglycemia.

 

- Neurological diseases: Epileptic seizures, head injury, tumours, cerebral haemorrhage

- Old age

- Constipation

- Dehydration

- Pain

 

CLINICAL FEATURES

 

-Disturbed consciousness manifested by confusion, drowsiness, decreased awareness of the surrounding, disorientation in time, person and place and distractibility.

 

Hallucinations- Visual, auditory, olfactory and tactile, gustatory.

 

 

DEMENTIA

 

This is an irreversible Organic Brain Syndrome which is a generalised impairment of intellectual ability, memory and personality with no impairment of consciousness caused by brain disease or injury and it can be acquired as distinct from amentia(Mental Retardation) which is present from birth.

 

ONSET                                                                                                                          

The onset and course is slow, insidious, progressive and terminal. It takes 8 – 10 years from the time the disease begins to the time of death.

 

Dementia comes in phases or stages namely:

 

PHASE/STAGE 1

Common features in this phase

-The client in this phase would show short term memory problems.

- Difficult in paying attention and concentration.

- Becomes ambivalent (uncertain in actions or thinking)

- Difficulties in making decisions

- Loses interest in the environment, events and situations(apathetic).

- Demonstrates deterioration in social activities.

- Covers up errors

 

PHASE/STAGE 2

Common features in this phase

 

- Demonstration of obvious memory loss/deficit

- Hesitation with verbal initiation or response

- Disorientation to time, place and person

- Complains of neglect

- Forgets appointments, routines and events

- Accuses others of stealing

- Hides his/her property but forgets location/place

 

 

 

 

PHASE/STAGE 3

 

Common features in this phase

-        Severe memory loss

-        Disorientation to date, person, time and place

-        Displaying motor deterioration

-        Immodest behaviour

-        Inability to recognize oneself in the mirror

-        Needing help on all daily activities

-        Unsteady gait

-        Inability to write or read

 

PHASE/STAGE 4 (TERMINAL STAGE)

Common features in this phase

-        Global memory loss

-        Psychotic behaviour- violence, aggression, irritability, crying anyhow etc

-        Ataxia

-        Inability to recognize anyone

-        Inability to eat or feed oneself, but fed directly or through tube

-        Incontinence with urine or stool

-        Resistance to bathing

-        Marked weight loss

-        Susceptibility to infections

-        Death

 

AETIOLOGY

A)    DEGENERATIVE BRAIN CELLS

This is common in:

-        Senile dementia,

-        Alzheimer’s disease,

-        Pick’s disease,

-        Parkinson’s disease,

-        Multi sclerosis,

-        Hydrocephalus etc

 

 

B)     INTRACRANIAL SPACE OCCUPYING LESSION

Such as:

-        Tumours,

-        Subdural haematoma.

 

 

C)     TRAUMA

-        Severe single head injury

-        Repeated head injury

-        Concussion such as boxers

 

D)    INFECTIONS

-        Encephalitis of any cause

-        Neurosyphillis (GPI).

-        Cerebral sarcoidosis

 

 

E)     VASCULAR DISEASES

-        Multi-infarct dementia

-        Occlusions of the carotid artery

-        Cranial arteritis

 

F)     METABOLIC DISORDERS

-        Sustained uremia

-        Liver failure due to cirrhosis

-        Renal dialysis

-        Remote effects of carcinoma or lymphoma

-        Hyper/hypothyroidism

 

G)    TOXIC SUBSTANCES

-        Alcohol

-        Poison with heavy metals such as, lead, arsenic, thallium

-        Cocaine

-        Dagga

 

H)    ANOXIA

-        Anaemia

-        Post anaesthesia

-        Carbon monoxide

-         Cardiac arrest

-        Chronic respiratory failure

 

I)       AVITAMINOSIS

-        Prolonged lack of vitamin B₁₂

-        Folic acid

-        Thiamine

 

 

GENERAL SIGNS AND SYMPTOMS

-        Incontinence

-        Restlessness

-        Aggression

-        Slow thinking

-        Loss of pattern of thought

-        Loss of feelings

-        Inactivity

-        Incoherent speech

-        Agitation

-        Self hygiene neglect

-        Disorganised behaviour

 

 

INVESTIGATIONS

-        CT scan

-        Renal function test

-        FBC, ESR

-        Reactive protein

-        Abnormalities will suggest infections or other problems that cause mental deterioration or confusion.

-        Assessment of cognition- interview patient, test memory, test attention, language skills and emotional test.

 

 

MANAGEMENT

NURSING CAREASSESSMENT

 

-        Establish cognitive status using standard measurement tools.

-        Determine self care abilities.

-        Asses threats to physical safety (e.g. wandering, poor reality testing)

-        Assess affect and emotional responsiveness

-        Asses ability and level of support available to care giver.

 

 

NURSING INTERVENTIONS

-        Speak slowly

-        Use short simple words and phrases

-        Introduce yourself

-        Address the patient by name

-        Focus on one piece of information

-        Review what has been discussed with the patient

-        Keep the patient in a well lit place

-        Keep clocks, calendars and familiar personal effects in the patient’s clear view.

-        Identify and acknowledge patient’s feelings if he/she becomes verbally aggressive.

-        If patient becomes aggressive, shift the topic to a safer and more familiar one.

-        Reinforce reality and acknowledge feelings of the patient if he/she becomes delusional.

-        Encourage decision making in a patient regarding ADLs as much as possible.

-        Keep patient in a well protected environment to prevent injuries as he/she wanders about.

-        Label patient’s clothes with the patient’s name, address and telephone number.

-        Encourage physical activity during the day time.

-        Install alarm and sensory devices on the doors of such patients.

-        Provide magazines  with pictures because reading and language diminish

-        Encourage patient to participant in simple, familiar group activities, such as singing, reminiscing, doing puzzles and painting

-        Respond to the patient calmly.

-        Do not raise your voice

-        Remove objects that might be used to harm oneself or others.

-        Identify stressors that increase agitation

-        Distract patient when upsetting situation develops

-        Monitor food and fluid intake

-        Provide good food for patient some of which must be portable.

-        Sit with patient during meals and assist by feeding if not able to eat.

 

CHEMOTHERAPY

 

Give anticholinestrase which slow the progression of dementia by increasing the relative amount of acetylcholine.

 

The drugs given are:

-        Donepezil (Aricept)

-        Galautagumine (Reminyl)

-        Rivastigumine (Exelon)

-        Tacrine (cognex)

-        haloperidol

 

COMPLICATIONS

-        Fractures/injuries when patient falls

-        Aggression or violence

-        Wandering about leading to missing or being killed

-        Care givers especially loved ones may suffer from depression.

-        Patient neglect or abuse due caregiver stress and burden.