Confusion (delirium) Flashcards

Question

What are the reversible causes of delerium?

Answer 1

Reversible causes of delerium include: Drugs Emotion (mania or agitated depression) Low oxygen (ischaemia, congestive heart failure, stroke or pulmonary embolus) Infection Retention (urine or faeces) Ictal states Undernutrition Metabolic (thyroid function or organ failure)

Answer 2

Drugs Emotional illness (incl. depression/ schizophrenia Metabolic/ endocrine disorders Eye/ear/environment Nutritional/ neurologic Trauma Infections Alcoholism/ anaemia/ atherosclerosis

Answer 3

Mode of onset --\> acute/ subacute Poor attention --\> characteristic Concsious level --\> often affected --\> may be wild fluctations hallucinations/ misinterpretations --\> common fear, agitation, aggression --\> common Exteremely disorganised thought patterns w unrealistic ideas --\> common, often flights of fancy Motor signs --\> myoclonus, postural tremor, flapping tremor (asterixis) speech --\> slurred dysphasia --\> none Dyspgraphia --\> often prominent short and long term memory --\> poor

Answer 4

Mode of onset --\> chronic, subacute poor attention --\> later event Consious level --\> normal Hallucinations and misinterpretations --\> late events fear, agitation, aggression --\> not common in early stages Extremeley disorganised thought patterns w unrealistic ideas --\> late feature (poverty of thought) Motor signs --\> none or late feature speech --\> normal dysphasia --\> often present dysgraphia -\> if present in keeping w degree of dementia short/ long term memory --\> often normal until late

Answer 5

* Amount of neural cell death and neuroinflammatory response determines development of delerium vs dementia * levels and duration of inflammation and response to this determines outcome * Inflammatory mediators cross the BBB * Causes activation of the microglia * Triggers neuroinflammation * Dysfunction or death will ensue: * neuronal dysfunction --\> delerium of short or long duration * Short duration can return pt to normal * Long duration --\> pt will have some abnormality * neuronal death --\> dementia

Answer 6

Inflammation of tissue leads to: Decreased cholinergic activity --\> which has a knock on effect on the dopamine system Increased dopamine activity Increased serotonin activity --\> boots up autonomic activity, increased HR, increased agitation levels Decreased GABAergic transmission (cholingeric pw interacts massively with GABA) Increased stress hormones Key area that will be affected by cortisol --\> amygdala (fear and hallucination).

Answer 7

Hallucinations are perceptions in the absence of external stimuli Common hallucinations include: Auditory hallucinations --\> voices and sounds Tactile/ somatic/ gustatory hallucination --\> feeling bodily sensations Visual hallucinations --\> seeing patterns/ images Olfactory hallucinations --\> smelling a foul or pleasant odour

Answer 8

Delerium Dementia Psychiatric disorders --\> schizophrenia, psychosis Drugs (lsd), alcohol, medications Epilepsy -- \>focal seizures Narcolepsy Visual impairment --\> charles bonnet syndrome Hallucinations can be normal : --\> part of grief process --\> hypnagogic (falling asleep) and hypnopompic (waking) hallucinations

Answer 9

* Commonly seen in people with severe visual impairment * Brain "filling in" gaps * Visual only, often see animals and people, can be scary * patient knows they are not real

Answer 10

Hallucination --\> spontaneous activation of sensory centres as if you were actually percieving it, fMRI shows the activity within the visual areas/ perceptual areas Shows activity as if the hallucination is real Hallucinatory acitivity overrides actual sensory inpt Thought there is a temporary disconnect between the cortical and thalamic regions (not allowing real sensory info through the thalamus to the cortex).

Answer 11

Dopaminergic pathways Prefrontal cortex --\> dorsolateral and ventrolateral linking to the limbic systerm Anterior cingulate gyrus Basal ganglia --\> striatum Hippocampus Cerebellum --\> pattern of speech and thought are changed, become repetitive and rhythmic

Answer 12

Limbic system = group of deep cortical and subcortical structure which includes: Hippocampus Amygdala Nucleus accumbens (reward pw) Cingulate gyrus --\> reasoning pws cognitive function Mamillary body Thalamic and hypothalamic nuclei Entorhinal and perirhinal cortices Links to Insula (hidden lobe) moderates emotional responses and links limbic to homeostatic regions, also contains taste centre

Answer 13

Memory Learning Perception (sensory, emotional, spatial) Motivation

Answer 14

Interplay w/in limbic sx and particularly the pre frontal cortex aids integration. Integration of info relevant to: Arousal Learning Memory Emotion Higher cognition

Answer 15

Regions of the limbic sx are implicated in both positive and negative emotions Nucleus accumbens linked to reward wherase amygdala linked to negative emotion The uncinate fascicuus links the amygdala to the PFC the Insula sets the threshold of the response Hippocampus puts everything into context and remebers it

Answer 16

Pre frontal cortex refers to any region of the frontal lobe preceding the motor areas Main roles: integration and decision making Responsible for personality

Answer 17

1) Restraint behaviours: concentration judgement foresight focus 2) initating behaviours motivation/ drive spontaneity personality curiosity 3) ordering behaviour Planning/ sequencing Working memory Abstract thought Perspective

Answer 18

Massive connections between the PFC and limbic sx is the **uncinate fasciculus.** It connects the **PFC to the uncus.** (Uncus is the anterior most part of the parahippocampal gyrus, part of the olfactory cortex) Massive interconnection between **PFC and primary sensory areas.** **Insula sets emotional thresholds** Any change in tract activity detected in confusion, psychotic episodes, major depressive disorders and bipolar disorders.

Answer 19

The uncinate fasciculus Raised ICP can lead to uncal herniation which can compress the uncinate fasciculus, changing the interplay between the PFC and limbic system.

Answer 20

1. Default mode network * Medial temporal cortex * medial prefrontal cortex * posterior cingulate gyrus * tells you where you are 2. Dorsal attentional network (oreinting and processing) * Dorsolateral prefrontal cortex * Posterior parietal cortex * Corpus striatum * Whats happening around you 3. Ventral attentional network (engagement and activation) * Basolateral amygdala * Lateral and inferior frontal cortex * temporoparietal cortex * Ventral striatum * how you're going to interact

Answer 21

* Remain calm * talk in short simple sentences * check they have understood and repeat if necessary * glasses and hearing aids * reassure them about where they are and how they are doing * keep hx taking short

Answer 22

* DSM diagnosis of delerium due to a medical condition? * Disturbance of **conciousness** with *decreased clarity of awareness* and *difficulties of attention* * **Change in cognition** --\> *memory deficit and disorientation,* presence of *perceptual abnormality* (changes must not be the result of previous/ evolving dementia) * The disturbance develops over **short period of time** and **fluctates** * Evidence disturbance is a result of a general **medical condition**

Answer 23

CAM = confusion assessment method Diagnosis of delerium with CAM requires the presence of features 1 and 2 and either 3 or 4 * Feature 1 --\> Acute onset and fluctuating course * usually obtained from fam member/ nurse * "is there evidence of acute change in mental status from patient's baseline?" "has the abnormal behaviour fluctated during the day/ increase or decrease in severity?" * Feature 2 --\> Inattention * Did pt have difficulty focussing attention e.g. being easily distractable, or having difficulty of what was being said? * Feature 3 --\> disorganised thinking * "was the patients thinking disorganised or incoherent?" * Feature 4 --\> Altered level of conciousness * Feature shown by any answer other than alert to the following: * Overall how would you rate this patient's level of conciousness? (alert, vigilant, lethargic, stupor, or coma)

Answer 24

1. Alertness 2. AMT4 (Age, DOB, place, year) 3. Attention 4. Acute change or fluctation

Answer 25

**Find and treat the underlying cause** **Supportive management:** * Clear communication * consitency of staff * family and carer involvement * prompts to day and time * familiar environment * adequate nutrition and fluids * low stress environment

Answer 26

* Patients need a full examination to ensure nothing is missed * Calm and reassuring * Relatives/ cares present may help

Answer 27

Admission prevention CERT team District nurses Social worker GP Community nurse for older people

Answer 28

medical management of delerium is a last resort --\> only use medication if the patient is severely distressed and unable to be alleviated by other measures, or at risk of harm to self or others. This is because medication might make the delerium worse or complicate the underlying cause.

Answer 29

Advanced age, advanced cancer Underlying brain disease (dementia, stroke, parkinsons) Organ failure (lung/ heart/kidney/liver) Limb fracture Immobilisation (incld. physical restraints) Frailty, malnutrition use of multiple medications (psychiatric drugs/ sedatives in partc.) OR multiple medical problems suddent withdrawal of medicaiton/ cessation regular alc use Undertreated pain Interventions (incld. diagnostic tests) Use of bladder catheters Poor eyesight/ hearing Sleep deprivation

Answer 30

1. Environment: * App. lighting, clear signage * clock and calendar easily visible to pt at risk * reiorientate pt, explain where they are, who they are, what your role is * Introducte cognitive stimulating activity * faciliate regular visits from fam/ friends 2. Sensory input * make sure pts have hearing aids/ glasses 3. Review medication 4. Infection 5. Nutrition and hydration * make sure pts have dentures * assist with eating and drinking if necessary