7. Delirium: etiology, diagnostic criteria, and clinical management

Question 1

Delirium def

Answer 1

medical emergency.
It may be the only early manifestation of serious illness.

Potentially reversible; can advance to coma, seizures, and death

Question 2

Delirium DSM-5 diagnostic criteria:

Answer 2

a. disturbance in attention and awareness
b. develops over short period of time and fluctuates in severity
c. disturbance in cognition (memory, disorientation, lang, perception)
d. evidence shows that the disturbance is a direct physiological consequence of another medical condition

Question 3

DSM-5 recognized five broad categories of delerium

Answer 3

1) Substance intoxication delirium
*
2) Substance withdrawal delirium
*
3) Medication-induced delirium
*
4) Delirium due to another medical condition
*
5) Delirium due to multiple etiologies

Question 4

delerium is most common in

Answer 4

• Up to 50% of hospitalized elderly patients develop delirium

Question 5

mortality rate in delerium

Answer 5

up to 40% of individuals die within 1 year of diagnosis

Question 6

Etiology of delerium

Answer 6

• Metabolic diseases (Most common cause)
• Infection (UTIs (most common cause in older patients) , Pneumonia
• CNS pathology
• Drugs and toxins (toxic encephalopathy)
  oAnticholinergics
  oBenzodiazepines, opiods, heavy metal
• Cardiorespiratory conditions (Hypoxia, Acute cardiovascular disease, Dehydration)
• other: Major surgery, Trauma

Question 7

etiologies of metabolic diseases that can cause delerium

Answer 7

▪ Liver or kidney failure
▪ Diabetes mellitus (diabetic ketoacidosis)
▪ Hyperthyroidism or hypothyroidism
▪ Vitamin deficiencies (e.g., vitamin B12, folic acid deficiency, thiamine deficiency)
▪ Electrolyte abnormalities

Question 8

types of delerium based on psychomotor activity

Answer 8

• hyperactive: agitated, refuse to cooperate
• hypoactive : lethargy, common in elderly
• mixed: normal level of psychomotor activity but attention and awareness disturbed, rapidly fluctuates (most common)

Question 9

what labs ordered incase delerium is suspected

Answer 9

Blood glucose
Pulse oximetry
ABG
Electrolytes
ECG
o Basic metabolic panel
o CBC with differential
o Urinalysis and urine culture
o Blood culture
Urine toxicology screen
o Blood alcohol level
o Therapeutic drug levels (antiepileptics, digoxin, lithium)
o Liver function tests
o Renal function tests
o Chest x-ray
o Head imaging (CR or MRI), EEG, lumbar puncture

Question 10

Indications for brain imaging:

Answer 10

o
No underlying cause evident on initial evaluation
o
In the context of head trauma
o
New focal deficits detected on exam
o
Patient unable or unwilling to cooperate with a neurological examination
o
No improvement despite treatment of already identified cause

Question 11

Management of delerium

Answer 11

• Treat the underlying cause
• Address potential exacerbating factors: mobility limitations, sensory deficits, sleep cycle disruption, urinary retention, dehydration, electrolyte abnormalities, medications
  *Reorient the patient on a regular basis regarding time, place, and situation
  oEnsure sunlight during the day
  oPlace calendars and clocks
  oEncourage family members to stay at the bedside
• Antipsychotics: indicated when agitation dangers the patient or others
  oHaloperidol (1st gen’ antipsychotic) – administered PO, IM, or IV
  oMay worsen extrapyramidal symptoms; use with caution in patients with Parkinsonism
• Avoid unnecessary restraints and drugs that may worsen delirium (e.g., benzodiazepines, opioids, and anticholinergics)

Question 12

drugs to avoid if delerium suspected

Answer 12

Avoid unnecessary restraints and drugs that may worsen delirium (e.g.,
* benzodiazepines,
* opioids
* anticholinergics