86. Delirium

Question 1

DSM-5 Diagnostic Criteria for Delirium (A-D)

Answer 1

A. disturbance in attention + awareness
B. short period of time, fluctuates in severity
C. disturbance in cognition (memory/language/hallucination)
D. evidence that disturbance is caused by direct physiological consequence of another general medical condition

Question 2

What clinical domains are affected by delirium (5)? Briefly describe the pathophys for delirium.

Answer 2

1. Impaired conscious/attention
2. Disturbance of cognition
3. Psychomotor disturbance (hyper/hypoactivity)
4. Circadian Rhythm disruption
5. Emotional Dysregulation
   1+ are affected

Pathophys: precipitants impact major domains = NT dysregulation or network disconnectivity = acute brain failure

Question 3

Describe the morbidity/mortality of delirium.

What are the 3 cognitive trajectories of delirium?

Answer 3

Higher risk of mortality with delirium in general illness
Higher morbidity due to more hospital days, more chronic cognitive syndromes, higher cost, PTSD

1. Complete Recovery
2. Incomplete Recovery - most pts have ongoing impairment
3. No recovery (chronic impairment)

Question 4

What are the top 3 predisposing factors to delirium?

What are the 2 key precipitating factors?

Answer 4

Age: more risk
Cognition: more dementia = more risk
Frailty: more risk

1. Systemic Brain insults
2. Toxins: Polypharmacy (>3 meds per pt - anticholinergics, benzos, opioids, CS)

Question 5

What are the 4 differences between dementia and delirium?

What is the triad of DLB?

Answer 5

Dementia: slow, over mo-yrs, good attention, bad memory, word finding problems
Delirium: rapid, over hrs-wks, bad attention, ok memory, incoherent speech

DLB: 1. Fluctuating cognition with changes in alertness/attention

2. Recurrent visual hallucinations
3. Parkinsonism

Question 6

What is the tx plan for delirium?

Answer 6

First line: Address underlying cause
Supportive: IV fluids, sleep-wake intervention, orientation aids, early ambulation

Antipsychotics: haloperidol (less impairment, shorter delirium)
Alpha2 agonists (decrease days of delirium)