Chapter 4. Delirium Flashcards
Question 4-1: Which of the following are typical clinical features of delirium? 1. Disorientation 2. Altered level of consciousness 3. Disturbed sleep-wake cycle 4. Acute change in mental status Select: A = 1,2,3. B =1.3. C= 2, 4.D=4 only. E = All
Answer 4-1: E. All of these are typical clinical findings with delirium. The acute change is one differentiation between delirium and dementia. Although the change is sudden, a fluctuating course is expected. Altered level of consciousness is typical along with disorientation and disturbance of the sleepwake cycle. Sleep deprivation due to the latter may exacerbate the cognitive and behavioral changes
Question 4-2: Important risk factors for the development of delirium in elderly hospitalized patients include which of the following? 1. Age 2. Visual loss 3. Pre-morbid dementia 4. Dehydration Select: A = 1,2,3. B =1.3. C= 2, 4.D=4 only. E = All
Answer 4-2: E. Age is a risk factor for hospital-associated delirium even within the elderly population. Patients over 80 years of age are much more likely to become confused. Visual loss also predisposes to delirium, since adaptation to the environment depends on evaluation of the environment Approximately half of hospitalized patients who develop delirium have an underlying dementia, and many of the rest have at least some cognitive difficulty
Question 4-3: Many prescription and over-the-counter medications have anticholinergic side effects. These can produce problems in elderly patients especially when used in combination. Signs of anticholinergic excess include all of the following except A. Hypothennia B. Dry mouth C. Confusion D. Flushing E. Mydriasis
Answer 4-3: A Patients with anticholinergic excess present with fever rather than hypothermia because of the inhibition of sweating. All of the other findings are typical of anticholinergic excess. The range of medications with anticholinergic effects is broad. ranging from tricyclic - antidepressants to antihistamines.. from medications used for pazkiosonian tremor (trihexyphenidyl) to neuroleptics used in patients with dementia and delirium.
Question 4-4: A patient is admitted to the hospital for chest pain and is noted to be confused. Patient presents with complaints of memory loss for the past two months, has a normal examination except mental slowness and diffuse decrease in memory, affecting recent more than remote memory. A. Hospitalization-related confusion B. Dementia C. Aphasia D. Depression E. Schizophrenia
Answer 4-4: B. Mild dementia predisposes to hospitalacquired confusion. Patients have difficulty with attention and concentration. Decompensation during hospitalization is typical
Question 4-5:
Patient presents with the inability to follow purely verbal
commands yet can follow visual cues welt.
A. Hospitalization-related confusion
B. Dementia
C. Aphasia
D. Depression
E. Schizophrenia
Answer 4-5: C.
Wernicke’s aphasia pres<:nts with the ir.ability
of the patient to respond to purely.verbal
commands. The patient can usually follow
visual cues so well that the aphasia may not be
appreciated. (P34)
Question 4-6:
Patient develops confusion and agitation at night while in
the hospital, which resolves during the day. Patient tends to
be awake much of night and sleeps part of the day. Patient
sees bugs on the wall and reacts to visions of children
outside the window.
A. Hospitalization-related confusion
B. Dementia
C. Aphasia
D. Depression
E. Schizophrenia
Answer 4-6: A.
Hospital-acquired delirium is common in
elderly patients. Patterned wallpaper an be
misperceived as bugs and occasionally
spontaneous visual hallucinations an occur.
Disturbance of the day/night cycle is
expected. While mental status usually
improves during the day, the improvement is
not usually back to baseline. (P33)
Question 4-7:
Disturbance of the sleep-wake cycle in patients with delirium
can have which ofthe following clinical manifestations?
1. Wandering at night
2. Sundown syndrome
3. Daytime drowsiness
4. Sleep attacks with REM-onset sleep
Select: A= 1,2,3. B = I, 3.C=2,4. D=4ooly. E=AII
Answer 4-7; A.
Patients with delirium have disordered circadian rhythm with excessive drowsiness in the day, but frank sleep attacks or REM-onset sleep is not expected. However, REM overflow into waking may occur and contribute to the perception of sleep disorder. All of the other clinical findings are expected in patients with delirium. (P31)
Question 4-8:
Delirium not only affects basic cognition and mood but also
other cognitive functions, although some functions can be
relatively preserved Which of the following abilities are
typically preserved in patients with delirium?
1 Writing
2 Visual object recognition
3 Drawing and constructions
4 Speaking
Select: A= 1,2,3. B = 1.3. C= 2,4.0 =4ooly. E = All
Answer 4-8: D.
Speaking is preserved in most patients with delirium. though the content is disturbed, reflecting the cognitive disturbance and thought disorder. Identification of the hallucinations. delusions, and paranoid is mainly through verbal communication.
However. writing is frequently affected., since the complexity of be intact neuraI network required to write precludes integrity of writing ability for most patients. Visual object recognition, drawing, and constructions are typically affected. (P31)
Question 4-9:
Which of the following metabolic derangements should be
considered in the differential diagnosis ofdelirium?
1 Hyponatremia
2 Hypoglycemia
3 Hypercarbia
4 Hypoxia
Select: A = 1,2,3. B = 1.3. C =2, 4.0 =4 only. E =All
Answer 4-9: E.
All of these are typical metabolic causes of delirium. Metabolic derangements are the most common causes of delirium. and should be considered in virtually all patients. These four metabolic derangements may be unassociated with other neurologic deficit (P36)
Question 4-10
Which is the best way to handle the sleep disturbance of
hospitalized patients with delirium?
A. Frequent staff visits to check on the patient
B. Aggressive stimulation of the patient during the daytime
C. Nightly phenobarbital to assist sleep and lessen agitation
D. Provide a familiar environment with calendar, family
pictures, personal items
E. All of the above
Answer 4-10: D.
A familiar environment can allow the patient to be less fearful and agitated during the day and more likely to be able to rest at night Frequent staff checks disturb sleep, so should
be minimized. Overstimulation when awake may make agitation worse, and can even disturb subsequent sleep. Phenobarbital should be avoided because of the cognitive effects which are typical and the paradoxical effects which are unusual, but very disturbing, if they develop. Although drugs should be avoided, nightly benzodiazepines or neuroleptics are needed for some patients. (P3840)
Question 4-11:
Which of the following statements is true regarding the
prognosis of patients with delirium during hospitalization?
1. Most show some recovery
2. Recovery is often incomplete
3. Pre-existing incipient dementia may be more evident
following the hospitalization-associated delirium
4. Recovery to a baseline may take months
Select: A = 1.2.3. B = 1.3. C = 2,4..D= 4 only. E-All
- Answer 4-11: E.
All statements are true. Most patients with delirium during hospitalization show some recovery, though the recovery may not be to pre-hospitalization levels. Dementia which may have been developing prior to the
hospitalization may be exacerbated and moreclinically evident following the hospitalization. Although most patients exhibit recovery in a few weeks, it may take three months for a new baseline to be established. (p40)
Question 4-12:
Which of the following cerebrovascular disorders would be
expected to be associated with delirium?
1. Bilateral carotid stenosis
2. Right middle cerebral artery infarct
3. Thalamic stroke
4. Unruptured posterior communicating artery aneurysm
Select: A = 1.2,3. B = 1.3. C = 2. 4.0 = 4 only. E = All
Answer 4-12: A.
An unruptured posterior communicating artery aneurysm would not normally be expected to produce delirium, although a ruptured aneurysm with subarachnoid hemorrhage commonly presents with delirium. Bilateral carotid stenosis, right MCA infarct, and thalamic infarcts commonly have associated delirium. (P37)
