Ch 27 Delirium Flashcards
Delirium definition
Reversible, acute onset condition that develops over a short period of time.
Results in fluctuating and transient global cognitive dysfunction
Is delirium considered a syndrome or a specific disease process or disorder?
Syndrome because of the many causes of delirium
Diagnostic criteria for delirium
Disturbance of attention and awareness.
Acute onset and fluctuation.
Other cognitive impairments.
Disturbance of attention and awareness means?
Reduced ability to direct, focus, sustain, shift attention. Reduced orientation to the environment
Acute onset in fluctuation means?
Hallmark features
Three subtypes. Hyperactive, hypoactive, mixed.
Other cognitive impairments means?
Additional disturbance in cognition:
Perception disorders, delusions, hallucinations, Psychosis.
Difference between encephalopathy and delirium.
used interchangeably
But encephalopathy describes both acute and chronic conditions.
Delirium is an acute condition
Delirium differential diagnosis acronym
I WATCH DEATH
DELIRIUM ACRONYM I WATCH DEATH MEANS
Infection. Withdrawal. Acute metabolic. Trauma. CNS pathology. Hypoxia. Deficiencies. Endocrine northeast. Acute vascular. Toxins or drugs. Heavy metals.
Contributions to delirium
Neurotransmitter system dysfunction.
CNS response to inflammation.
Hypothalamic pituitary adrenal axis dysregulation.
Direct cerebral insults or injury.
Dysfunction related to delirium occurs at what level
Cellular and neurotransmitter level
Which mechanisms are most likely being disrupted in delirium
Reticular activating system, subcortical, cortex
Neurotransmitters involved in delirium
Acetylcholine
- for attention, memory, arousal.
- High level of Acetylcholine is related to delirium
Dopamine
- excess dopamine causes hallucination.
- Bupropion can exacerbate delirium
- Levodopa can cause hallucination, agitation
Serotonin
- disruption or over excitation of serotonergic systems can cause hallucination and emotional lability
Risks factors for delirium
Predisposing factor. Old age, dementia, severity of physical illness, multi drugs, metabolic disturbances, depression, sensory loss, respiratory problems, myocardial infarction, infection Sleep deprivation, sensory impairment, mobility, functional decline, dehydration, pain, medical comorbidity.
Independent risk factor associated with delirium
Age is an independent risk factor
Precipitating factors for delirium
Surgery, side effects of drugs, drug withdrawal, infection, metabolic derangement, pain.
Prevalence of delirium
14% age 85 and above
Types of delirium and prevalence in critical care settings
Most common is
- mixed type delirium,
- hypoactive,
- hyperactive
Type of delirium and prevalence and non-critical care setting
Hypoactive delirium is more common
Common causes of delirium in elderly
Infection
Cause of delirium in young adults
drug abuse and withdrawal
Common causes of delirium and children
Medication side effects
Percentage of people experiencing permanent cognitive impairment following resolution of delirium
Up to 50%
Other morbidity of delirium
Impulsively, picking up skinner clothes, agitation all leading to an unintentional injury
Chance of death who survived delirium
35 to 40%
Presentation of delirium - two general courses
- Abrupt immediate onset.
Can occur with moderate or severe TBI or stroke.
Neurological event causes confusion and behavioral change.
2. Slow onset or fluctuating course prodromal period, symptoms develop over hours or days. islands of lucidity Syndromes wax and wane. Mild to moderate cognitive impairment.
What do EEG findings show in delirium
Typically abnormal EEG especially in metabolic delirium
What is an important cognitive function to assess for in differentiating delirium
Attention and sustained attention.
Characteristics of hallucinations and delusions associated with delirium
Delirium, hallucinations and delusions are unsystematic, variable, can be formed and unformed.
In psychosis. they are typically formed with distinct shapes, objects, people, scenes.
Examples of hallucinations and delusions in delirium
Formication hallucination.
- Feeling of bugs crawling over the skin.
- Suggest drug withdrawal delirium.
acute interventions at the ED with delirium?
IV fluids
thiamine
glucose
examples of medications used in delirium
benzos - counter alcohol withdrawal
neuroleptics - address hallucination and sleep problems
GABA targeted drugs for agitation
charles bonnet syndrome
visual hallucination in people who lose eyesight.
perception of faces, small objects, people
aware that they are not real
Autonomic storms
reaction to autonomic nervous system to severe injury, metabolic disturbance, overstimulation
HTN, tachycardia, diaphoresis
common cause - SCI, substance use, meds side effects, TBI
neuroleptic malignant syndrome
complication following neuroleptic use
- muscle rigidity
- pallor
- dyskinesia
- hyperthermia
- incontinence
- unstable blood pressure
- tachycardia
- pulmonary congestion
Delirium tremens
global confusion
hallucination
autonomic hyperactivity
Wernicke’s encephalopathy
confusion
(ocular) abnormalities.
ataxia of the eye - cannot control eye voluntarily
AOC - cortez
serotonin syndrome symptoms
tremor diarrhea diaphoresis mental status changes hyperreflexia fever incoordination
Vitamin b12 deficiency sx
Anemia, weakness, fatigue, mood changes, memory loss, disorientation. Impaired recognition of pressure, difficulty walking, tingling or numbness, irritability, depression, impaired attention, hallucinations, impaired proprioception
definition of embolic shower
pattern of multiple, acute cortical strokes in different vascular territories
Coronary artery bypass graft
cardiac valve replacement surgery
are usually associated with what condition
Embolic shower
Hyponatremia
electrolyte disturbance
sodium concentration low
water accumulates in the body at a faster rate than it can be excreted
can lead to cerebral edema (e.g. congestive heart failure, polydipsia)
25% cases are postoperative
What factor is most predictive of persistent cognitive impairment and complications of delirium
Length of delirium
Hyperatremia
electrolyte disturbance
sodium concentration too high
caused by dehydration or conditions that result in excessive water loss (.e.g diarrhea, gastroenteritis)
causes dehydration –> delirium
types of hallucinations
formication - bugs crawling over skin
hypnagogic - when falling asleep
hypnopompic - in the process of awakening, together with sleep paralysis
lilliputian - formed visual hallucination, objects seen smaller than in real life
metamorphorsia - one’s body changing in shape or size (alice in wonderland)
misidentification - objects, people being duplicated
peduncular - vivid, motion filled. perception of small objects. pleasant and entertaining (POSTERIOR STRUCTURES)
Release - occurs 2/2 sensory loss (Charles bonnet, phantom limb)
Visceral - sensations stemming from internal organs, unpleasant, hard to localize
