Delerium

Question 1

Px

Answer 1

Acute confusion. Acute onset cog impairment assoc with behav abn. More comm if chronic brain prob exists.
-feats-
Impaired direc, shift, focus and maint of atten. Imapired conciousness from clouding to coma.
Global impair cognition with disorientation, impaired recent mem and abstract think. Impaired comprehension. Disorientation in time, and place person if more sev.
Sleep cycle distrub- Nocturnal wakening, insom, reversal, daytime drowsy, nightmares.
Psychomotor disturb- hypo/hyperactive, incr reac time, incr/decr flow of speech, incr startle reac, agitat.
Emot distrub- lability, agitat, dep, anx, irrit, euporia, apathy, perplexity.
Perceptual distrotions, illusions, hallucins- us visual.
Speech rambling, incoherent, thought didordered.
Transient delusions.
Onset rapid (hrs or days) with flucs in severity over mins or hours.
-3 common presentations-
Hyperactive or agitated- more psychotic symps.
Hypoactive- less psychotic and less speech.
Mixed- most fluc btw hyper and hypo.

Question 2

Diffs

Answer 2

Mood disorder
Psychosis
Post ictal
Dementia

Question 3

Aetiology

Often multi fac

Answer 3

Infective eg UTI, chest, abcess, cellulitis, SBE.
Metabolic eg anaemia, elec, enceph, uraemia, HF, hypothermia, hepatic or renal fail.
Intra cranial eg CVA, head inj, enceph, tum, RICP.
Endoc eg pit, thyr, PTH, adrenal, gluc, DM, vits.
Subst intox or withdraw eg alc, BDZ, antichol, lith, antiHTN, diuretics, anticonvulsant, digoxin, steroid, NSAID, psychotropics.
Hypoxia.
Trauma- inflam casc. Affs neuone func and HPA.
-predisp- eld, male, sensory imapir, dep/dementia, func impair, malnutr, CVS/parkinsons.
-precip- meds eg cholinergic, infec, metab abn, hypox, shock, anaem, sleep dep, pain, surg, neuro illness.
-delerium eff on brain- low ach, high dop 5HT glutamate. Neurone death. Glial death. Low BDNF causes atrophy.

Question 4

Prognosis

Answer 4

Sudd onset then flucs. 
Grad resol as tx cause. Slow in eld. 
Amnesia of event afterwards. 
20% mort dur admiss, 50% after 1 yr. 
subseq dementia more likely.

Question 5

Mx

Answer 5

-Id and tx cause. Eary recog.
-supportive measures incl educ and reality orientation. Inv fam. Consis nursing. Avoid transfer. Expl intervens. Env feats eg calm env, large clocks, easy read notices, adjustab lights, partcicp in ADL. Remove catheter. Correct sensory difict.
-Avoid sedat unless sev agitat, risk to others, or for investig or tx. Use single low dose and titrate up. Reassess in 2-4hr bef prescribing regulalrly. Eg holperidol, lorazepam, risperidone. Pref antiP than BDZ unless related to alc withdrawal. Avoid physic restraint.
Haloperidol- rel mild sedation, rel few antichol se, IV admin means fewer EPSE, torsades de pointes. Can add to confus to cautious dosing.
BDZ bad- cana ggrev delerium, less effec than antiP, more chance over sedat, disinhib.
-regul review and follow up. MMSE usef.

Question 6

Prevalence

Answer 6

13.6% over 85.
About 50% cases are mixed.
10-20% medical inpts. Higher for surgical inpt.
10-30% of eld px to AE.