Central Nervous System - altered mental status ( Delirium, Dementia, Normal Pressure Hydrocephalus, Psychosis) Flashcards
What is the definiton of delirium?
- acute or sub acute state of cognitive dysfunction caused by underlying medical condition
What is the diagnostic criteria for Delirium
- clouding of consciousness
- reduce ability to focus, sustain or shift attention
- A cognitive change eg ( memory deficit, disorientation, language disturbance) or
- Perceptual disturbance that is not better accounted for by pre- existing, established or evolving dementia
- Disturbance occurs over hrs to days
- Tends to fluctuate during the course of the day
- Evidence from Hx, exam and investigation of medical condition as the course, Drug, med withdrawal
What is the incidence of Delirium?
- unknown in ED
- Occurs 10% of elderly population presenting in ED and in the medical ward.
- 16 to 24% in rehab ward >70yr old patient.
- 40% in Neurological services
What are the predisposing factor for delirium?
- advanced age
- pre existing dementia
- underlying medical illness
- Multiple medications / drugs and alcohol
- Severe psychological stress and sleep deprivation
What are the pathophysiology of delirium?
- Widespread alteration to the cerebral metabolic activity with secondary degradation of neurotransmitter synthesis and metabolism
- Exact Pathophysiology is not clear but several pathways are implicated – Acetylcholine transmission and serum anticholinergic activity
What are the aetiology?
I WATCH DEATH I - infection Withdrawal (alcohol,drugs etc) Acute metabolic acidosis Trauma to head + BURN CNS - pathology Hypoxia Deficiency - vitamins Environmental/endocrinology Acute vascular Toxins and drugs Heavy metal
What are the clinical findings
- Natural history can progress form apathy to marked agitation over the cause of hours.
- Disturbance in attention is central to the diagnosis of delirium ( distractible and has difficulty focusing on a particular topic)
- Disorientation to time and occasionally place ( A few orientation may be intact)
- Impairment of short term memory with inability to learn or assimilate new information.
- Perceptual disturbance – poorly formed delusions and hallucinations
- Exam – vital signs/ top to bottom , Don’t forget a mental status examination
What are the CAM - Confusional Assessment method
Only four features 1) acute onset 2) fluctuating course during the day 3) inattention and disorganized thinking 4) altered level of consciousness Positive – first 2 and at least one of the last 2. Good inter observer reliability
Sensitivity – 93% to 100% and Specificity 90 to 95%)
What are the differential diagnosis of Delerium
- functional psychiatric disorders and dementia i.e. Depression, mania, paranoia and schizophrenia.
- The above have an early onset in life.
What are the management of Dementia?
Safety – if there is aggression and safety issue to patient and staff
Chemical restrain is the corner stone but Physical restrain may be required temporarily to initiate control.
a) Activate alert for retrain of patient (for staff to assemble)
b) Move patient to appropriate area for safety issues to staff and the patient as well as minimized impact on other patient.
c) Technique of restrain
d) Medication
Haloperidol (2 to 5mg) in elderly (0.5 to 1 mg)
+ Lorazepam – 1 to 2 mg IM
- Medical emergency and outcome depend on the cause of delirium
- A – airway
- B- breathing
- C- Circulation
- D – disability / drugs
- E – electrolyte replacement/ Correction of endocrine problem
- F – fluid resuscitation if dehydrated or hypotension
- G – replace glucose / GU – treat UTI
- H – Hb replacement
- I – treat infection
Treat the underlying course - Supportive care
- Appropriate environment (Quiet, appropriate light intensity and easily observed by staff.
- Sitter often helpful as a constant remainder.
- Involve power of attorney or family member if emergency management
- Good documentation of what involve.
Disposition
- Majority required admission for ongoing management to reverse the cause of delirium. Especially longer with elderly.
How do you define Dementia?
- Slow decline of mental capacity( both cognitive and higher cortical function)
- hallmark is loss of short term memory but no clouding of consciousness (Normal attention)
- Hallucination / delusion is rare
What are the aetiology of dementia?
1) Alzheimers disease
- 70% of cases
- RF - genetic, obesity
2) Vascular dementia
- 15% of cases
- abrupt onset + stepwise deterioration
- aphasia prominent
- gait disorder
3) Dementia with Lewy bodies
- 10% cases
- hallucinations / delusions common
- Significant fluctuations in level of consciousness or cognitive abilities
4) Frontotemporal dementia
- 10% cases
- prominent behavioural changes
- profound apathy, aphasia
5) Parkinson disease
6) Viral - HIV, Creutzfeldt jakob disease
What are the epidermiology for Dementia?
- < 1% 85 years of age
- Frequency expected to rise 400% in the next 20%
What are the features ot Dementia?
- memory loss
- apathy
- depression
- irritability
- aggression/agitation in 25%
- delusions in 20%
What are the diagnostic criteria for Dementia?
1) Cognitive loss in 2 or more domains
- memory, language, calculations, orientation, judgement
2) Loss must be sufficient severity to cause disability
3) Usually MMSE < 24
4) clinical diagnosis only
