90B Delirium

Question 1

DSM delirium criteria

Answer 1

A) reduced ability to focus
B) change in cognition (memory, language, orientation) OR perceptual disturbance not due to dementia
C) Develop over hours-days AND fluctuates
D) Evidence that its due to general medical condition

Question 2

What part of the CNS may have significant disruptions in delirium?

Answer 2

reticular formation (activating system)
thalamus (relay system)

Question 3

What are associated findings in delirium?

Answer 3

• sleep-wake disruption: less deep sleep (4) and REM; no sleep consolidation
• Emotional dysregulation

Question 4

Why is it important to catch delirium early?

Answer 4

Increased mortality (immediate and 6 month) and morbidity (longer hospital stay, cognitive issues, costs)

Question 5

what are the major risk predisposing risk factors for delirium?

Answer 5

Age

Cognition - dementia

Question 6

Precipitating factors leading to delirium - acronym

Answer 6

I WATCH DEATH
Infections (UTI, Pneumonia)
Withdrawal (EtOH, Benzodiazepines)
Trauma (post-op)
CNS Pathology
Hypoxia
Deficiencies (B1, B12, folate)
Endocrine (glucose, thyroid, hyperparathroid)
Acute Vascular
Toxins (medications, poisonings)
Heavy Metal

Question 7

Toxins leading to delirium

Answer 7

Polypharmacy (>3 meds) = high risk of psychoactive activity

1) anticholinergic meds
2) benzodiazepines (rx for anxiety pre/post-op)
3) opioids (rx for advanced cancer patients)
4) corticosteroids

Question 8

What opioids that are more psychoactive/deliriogenic?

Answer 8

Meperidine
Morphine (switch to fentanyl)

Question 9

Delirium evaluation should include what?

Answer 9

History
Physical
Cognitive testing –> attention (CAM test - confusion assessment method)

Question 10

onset and duration of dementia vs delirium

Answer 10

dementia is slow and lasts months/years

delirium is fast and lasts hours/weeks

Question 11

Attention in dementia vs delirium

Answer 11

dementia - preserved; delirium - fluctuates

Question 12

Awareness in dementia vs delirium

Answer 12

dementia - unchanged; delirium - reduced

Question 13

Dementia with lewy bodies vs delirium

Answer 13

movement (parkinsonism) in dementia with lewy bodies

Question 14

Delirium work up

Answer 14

vital signs
CBC 
Chem-12
Mg, Ph
urinalysis + drug screen
\+ others

Question 15

EEG utility in delirium work up

Answer 15

differentiates from seizures and psychiatric disorders

Question 16

Delirium first line treatment

Answer 16

Treat underlying cause

Question 17

What are supportive treatments for delirium?

Answer 17

IV fluids
sleep-wake interventions
orientation aids
remove restraints
ambulation and mobility

Question 18

Pharm treatments for delirium

Answer 18

IV Haloperidol #1

2nd generation Antipsychotics

Question 19

Haloperidol improves what?

Answer 19

shorter time delirious
less cognitive impairment 
improved sleep wake
less restraints
less BP issues

Question 20

Haloperidol warnings

Answer 20

Torsades and QTc prolongation

Question 21

Delirium preventation

Answer 21

Preventation and prophylaxis with olanzapine before surgery has shown positive results