1: Psychiatric complications of physical disorders (mainly delirium)

Question 1

What are the CAM criteria for delirium?

Answer 1

1. Inattention

2. Disordered thinking AND/OR Change in conscious level

3. Acute onset and fluctuating course

Question 2

What sorts of cognitive disturbances may delirious patients experience?

Answer 2

Impaired memory and attention

Thought disorder

Perceptual changes (hallucinations)

Disorientation (time, space, person)

Question 3

What are the two terms used to describe a patient’s psychomotor state?

Answer 3

Hyperactive (agitation)

Hypoactive (retardation)

OR it could be a mixed picture

Question 4

What is psychomotor retardation often misdiagnosed as?

Answer 4

Depression

Question 5

What sort of hallucinations are seen in organic problems?

Answer 5

Visual hallucinations

Question 6

What sort of hallucinations are seen in primary psychiatric illness?

Answer 6

Auditory hallucinations

Question 7

What is “sundowning” in the context of delirium?

Answer 7

Tendency for symptoms to worsen at night

So patients spend the day asleep and are awake (and often agitated) at night

Question 8

Which mood disorder is often misdiagnosed in delirious patients?

Answer 8

Depression

due to psychomotor retardation, sedation, apathy

Question 9

Do you need to have an identified cause of delirium to be officially diagnosed?

Answer 9

No

Underlying cause may have gradual onset or be in subclinical phase

Delirium is a clinical diagnosis

Question 10

What is the usual

a) onset
b) course
c) duration

of delirium?

Answer 10

a) Acute onset
b) Fluctuating course
c) Weeks to months

Question 11

What are the causes of delirium?

Answer 11

Virtually any disease

Question 12

Which group of patients is more susceptible to delirium?

Answer 12

Frail patients with co-morbidities

which tends to be the elderly

Question 13

Apart from diseases, what can cause delirium?

Answer 13

Drugs

Question 14

Which therapeutic drugs can precipitate delirium?

Answer 14

Anticholinergics

Anticonvulsants

Drugs used for PD - levodopa, dopamine agonists

Steroids

Question 15

Which recreational drugs can precipitate delirium?

Answer 15

Alcohol

Illicit drugs

Question 16

Use of drugs can cause delirium.

What else can precipitate it?

Answer 16

Withdrawal from drugs

alcohol, opiates, benzos

Question 17

Any significant ___ to the body can precipiate delirium.

Answer 17

insult

Question 18

How is delirium diagnosed?

Answer 18

Clinically

based off CAM criteria

Question 19

What age of patient is predisposed to developing delirium?

Why?

Answer 19

Elderly

Frail, more likely to have existing comorbidities

Question 20

A past psychiatric history of which illnesses predisposes a patient to delirium?

Answer 20

Delirium

Dementia

Question 21

Sensory ___ (e.g hyper/hypothermia) and ___ (e.g deafness, blindness) can precipitate delirium.

Answer 21

Sensory extremes and deficits

Question 22

After which intervention are patients particularly vulnerable to delirium?

Answer 22

Surgery

Perioperative period where patient is recovering

Question 23

Exposing a frail elderly patient to a new ___ may precipitate delirium.

Answer 23

new environment

Question 24

Apart from history and examination, how would you assess a patient’s cognitive function?

Answer 24

Formal cognitive testing

so 4AT, MOCA, ACE-III

Question 25

How can the environment of a patient with delirium be improved to prevent unneccessary distress?

Answer 25

Well lit, quiet

Orienting factors (e.g a clock, 24H news)

Minimise staff changes

Remove unneccessary equipment

Question 26

Which renal investigation should be done in patients with delirium?

Answer 26

Urinalysis

to exclude UTI

Question 27

Which blood tests should you request for a delirious patient?

Answer 27

FBC, WCC and inflammatory markers

LFTs and TFTs

Blood glucose

Vit B12 and folate

Question 28

Why must you do a urinalysis for a delirious elderly patient?

Answer 28

UTI is a common cause of delirium in the elderly

Question 29

What is the standard pharmacological management for delirium?

Answer 29

Antipsychotics e.g haloperidol

Question 30

Which class of drug is only used if necessary in agitated delirium patients?

Answer 30

Benodiazepines

Sedation lasts for a while, tends to worsen delirium

Question 31

What is the mean duration of delirium

a) in younger patients
b) in older patients?

Answer 31

a) 1-4 weeks in young patients

b) 4-6 weeks in older patients

Question 32

Which class of drug is used to sedate patients during alcohol withdrawal?

Can you name the specific drug?

Answer 32

Benzodiazepines

Chlordiazepoxide

Question 33

Under NHS Tayside delirium guidelines, which drug is used to treat delirium

a) in your average patient
b) in patients with Parkinson’s disease or dementia with Lewy bodies?

Answer 33

a) Haloperidol
b) Lorazepam

Question 34

Name a benzodiazepine which has a

a) short duration
b) long duration?

Answer 34

a) Lorazepam

b) Diazepam

Question 35

Which cardiovascular diseases carry a significant risk of patients developing depression?

Answer 35

Stroke

MI

Question 36

Which percentage of stroke patients develop depression?

Answer 36

33%

one third

Question 37

Which percentage of MI patients develop depression?

Answer 37

20%