Delirium Flashcards
Define delirium
acute decline in the cognitive processes of the brain
Why is delirium so hard to diagnose?
- changes fluctuate throughout the day; under recognition of these symptoms
- physicians use other terms rather than delirium
T/F: 2/3 cases of delirium go unreported …
if F, correct
TRUE
What is the A-E of Diagnostic criteria for delirium?
A. distubrance in attention and awareness
B. acute onset (fluctuates throughout the day)
C. disturbance in cognition
D. A & C not explained by another pre-existing condition
E. direct evidence (lab, history, etc) that disturbance is result of another medical condition, exposure to toxin, etc
Give 3 examples of cognitive disturbances..
memory deficit
- disorientation
- language
- visuospatial ability
- perception
T/F: perceptual deficits (illusions or hallucinations) are a common clinical feature of delirium…
(if F, correct)
TRUE
Which type of delirium is normally found with the elderly?
hypoactive
T/F: dementia, delirium and depression see diurnal effects (fluctuations throughout the day)
(if F, correct)
- F
- dimentia is progressive, and stable over time (no diurnal effects)
- delirium is usually worse at night and when waking
- depression is usually worse in the morning
T/F: Delirium sees fluctuations in alertness, whereas dementia and depression have normal alertness.
(if F, correct)
- TRUE (generally)
- people with delirium can be lethargic or hyper-vigilant
T/F: Memory is affected in all of delirium, dementia and depression.
(if F, correct)
- TRUE (generally)
- delirium sees recent and immediate memory impairment
- dementia sees recent and remote affected
- depression; memory can be patchy
What are characteristic traits of hyperactive delirium?
-restlessness
-constant movement
-agitation
-rapid speech
wandering
What is hyperactive delirium normally mistaken for?
- BD
- schizophrenia
- agitated dementia
What are characteristic traits of hypoactive delirium?
- slow movement
- unresponsiveness
- apathy
T/F: Hypoactive delirium is often mistaken for anxiety.
if F, correct
- F
- often mistaken for depression
What method is used delirium screening?
Confusion Assessment Method
CAM
What symptoms must a client have to have a positive CAM test?
- acute onset of symptoms and fluctuating course
- inattention
- disorganized thinking or altered level of consciousness
T/F: precipitating factors are considered predictive
if F, correct
- F
- predisposing are predictive
What is a predisposing factor (def)?
- any baseline characteristic that is present upon admission
- patient dependant
What are the major categories of predisposing factors? (7)
- demographic characteristics
- cognitive status
- functional status
- sensory impairment
- decreased oral intake
- drugs
- coexisting medical condition
Give 5 examples of predisposing factors..
(doesn’t have to be exactly these)
- dementia
- immobility
- history of falls
- alcohol abuse
- comorbid burden (stroke, depression, renal failure)
Define precipitating factor..
insults or factors related to hospitalization that contribute to a patient’s risk for delirium
What are the 6 categories of precipitating factors?
- drugs
- primary neurologic disease
- incurrent illness
- surgery
- environmental
- prolonged sleep deprivation
Give 6 examples of precipitating factors
- polypharmacy
- psychoactive drugs
- physical restraints
- abnormal lab findings
- meningitis
- intercranial bleeding
T/F: predisposing factors measure one’s vulnerability for delirium and precipitating factors measure the insults they encounter at the hospital
(if F, correct)
-TRUE
T/F: a highly vulnerable individual could only need one noxious insult to be exposed to delirium
(if F, correct)
-TRUE
T/F: there are also protective factors that make someone more vulnerable to experiencing dementia
(if F, correct)
- F
- make someone LESS likely
Give 3 examples of protective factors…
- younger age
- cognitive functioning
- good medical history and general functional status
What are the physiologic stressors related to the neurotransmitter dysregulation hypothesis of delirium? (2)
- cortisol
- hypoxia
T/F: lactic acidosis, hyper or hypoglycemia, IGF decrease, hypercapnia are all metabolic derangements that could lead to delirium
(if F, correct)
TRUE
What are the main electrolytes studied when discussing delirium? (3)
- sodium
- magnesium
- calcium
Which specific allele is associated with risk of delirium?
-e4 allele of apolipoprotein E
involved in the growth, maintenance and repair of myelin
True or false:
Systemic inflammation is a predominant part of many surgical conditions associated with delirium
TRUE
True or false:
there is not a strong link between delirium and inflammation
false
How do peripheral immune cells get to the brain
by altering expression of tight-junction proteins
What does higher blood levels of cytokines have to do with delirium?
patients with post-op delirium have higher levels than those without delirium
what is cascade effects of the brain being activated by peripheral immune cells?
causes cytokin production and neuronal cell proliferation
than the activation of HPA axis which can help to combat acute infection
These changes can contribute to delirium
What does the activation of microglia do?
induces changes and initiates production of pro-inflamatory cytokines like IL-1, 2 and TNF- ALPHA
True or false:
inattention and decreased cognitive function may be associated with increased cerebral blood flow
False: this sees decreased
What is the neuroinflammatory hypothesis?
changes in neurotransmission and cerebral blood flow may contribute to pathogenesis of delirium
what cant the neuroinflammatory hypothesis full account for? what can it explain?
cant explain all symptoms of delirium
can explain how peripheral changes to body can affect brain function
according to the Neuroinflammatory hypothesis, why are seniors more at risk for delirium
because of enlarged and damaged microglia in brains of elderly non-delirium patients
True or False:
microglial cells undergo age-related structural and functional changes
TRUE
What is the role of Acetycholine (ACh)
has in important role in memory and condition
patients with delirium have much less of it
Cholinergic Hypothesis of Delirium
neuroinflammation shown to induce cholinergic deficit in the brain along w/cerebral blood flow effect
Why can neither the neurofinalmmaotry and cholinergic hypothesis of delirium give full insite to derlium?
there are so many different factors and it is unlikely a single neurobiological pathway is responsible
what is the connection between anticholinergic drugs and healthy adults
it can cause delirium in healthy adults and it is more likely to cause delirium in the elderly as well
it lower the amount of ACh which is a cause of delirium
What type of drugs can cause drug- induced delirium?
ones that possess anticholinergic activity
True or false:
Opiate drugs are a common cause of delirium because they cause increased dopamine levels in the brain so there is more ACh
False! they cause less ACh due to raised dopamine levels
True or false:
Dopamine antagonist can treat some delirium symptoms
true
What is the common connection of medical conditional that precipitate delirium?
they decrease the ACh synthesis in the CNS
True or false: in studies, targeted interventions can reduce delirium risk by 40% in elderly
true
Intervention protocols for: Cognitive impairment
Orientation protocol and therapeutic activities protocol
Intervention protocols for: Sleep deprivation
non-pharmacological sleep protocols + Sleep enhancements
Intervention protocols for: Immobility
early mobilization
Intervention protocols for: Visual impairment
vision protocol
Intervention protocols for: Hearing impairment
Hearing protocol
Intervention protocols for: Dehydration
Dehydration protocol
Why should all patients have formal cognitive testing with CAM on intake?
to figure out a baseline to be able to see if delirium progresses
True or false:
if no history is available, delirium should not be assumed
false
Prevention of delirium in hospital setting
- Coordinating schedules for drug administration, obtaining VS, preforming procedures during night which prescribes for uninterrupted sleep period
- opening blinds + promoting wakefullness and mobility during day encourages regular sleep-wake cycles
True or False:
Delirium is often the sole manifestation of a serious underlying disease in elderly
true
what is the standard pharmacological management of delirium
antipsychotics are mainly used with low dose haloperidol and atypical antipsychotic therapy is good for managing symptoms
Why should high dose haloperiodol be avoided
Because of the increased risk of extrapyramidal side effects
what is the connection between delirium and dementia?
- they are highly interrelated
- dementia is a leading risk factor for delirium
- both conditions are associated w/ decreased cerebral blood flow, ACh deficiency and inflammation
What is the most significant factor for persistent delirium
use of physical restraints
Delusions are…
Fixed, false beliefs, cannot be corrected by logic and are not consistent with culture and education of the patient
Hallucinations are…
False sensory perception experienced without real external stimulus. They are usually experienced as originated in the outside world not within the mind as imagination.
Illusions are…
Misperception of real external stimulus. Most likely to occur when general level of sensory stimulation (consciousness) is reduced.
What is the most common delirium subtype?
Hypoactive
Precipitating Factor
something happening now, in hospital or care (like anemia post surgery)
Predisposing Factor
something in the patients past like concurrent type 2 DM and COPD
DRS
Delirium Rating Scale: used to rate symptom severity, follow the course of the syndrome, assess whether a patient’s symptoms are improving with treatment interventions. The CAM instrument cannot assess severity.
What must a patient exhibit to be diagnosed with delirium (CAM instrument)
(1)Acute onset of symptoms, (2)inattention, (3)fluctuating symptoms AND (4a) disorganized thinking OR (4b) altered L.O.C.
CAM
Confusion Assessment Method: diagnoses delirium by a yes or no answer to a four point algorithm based on DSM criteria.
- Acute onset
- Inattention (did this fluctuate?)
- Disorganized thinking
- Altered L.O.C. (alert, vigilant, lethargic, stupor, coma, uncertain)
- Disorientation
- Memory impairment
- Perceptual Disturbances
- Psychomotor agitation & retardation
- Altered Sleep-Wake cycle
Explain how predisposing and precipitating factors interact to affect patient vulnerability to delirium.
- Presence of 3 or more factors increases the odds of developing delirium by 60%
- patients who are high vulnerability will develop delirium after minor insult
- patient who are not vulnerable will develop delirium after noxious insult
Neuroinflammatory hypothesis (brief definition)
A hypothesis which links delirium and inflammation. Systemic inflammation increases permeability of the blood-brain barrier, causing infiltration of pro-inflammatory agents which results in changes in neurotransmission and blood flow.
Pathophysiology of the Neuroinflammatory hypothesis
- Immune response is initiated resulting in production of cytokines and activation of the HPA axis
- Peripheral immune cells alter tight-junction proteins which form the blood-brain barrier to gain access to the brain
- Increased permeability allows for infiltration of leukocytes and inflammatory agents into brain
- Pro-inflammatory agents activate endothelial cells, microglia and astrocytes
- Activation of microglia initiates production of pro-inflammatory cytokines (IL-1, IL-2, tumor necorsis factor- alpha)
- Changes within microglia modulate activity of endothelial cells, astrocytes and neurons to impact cerebral blood flow and signals propagation of neuronal excitability
What is the support for the neuroinflammatory hypothesis?
- There is a strong link between delirium and inflammation as delirium is a clinical feature of sepsis, UTIs, pneumonia, MI, fractures etc.
- Delirious patient have higher blood plasma levels of inflammatory cytokines than patients without
Cholinergic hypothesis (brief definition)
Also known as neurotransmitter dysregulation. Decreased levels of acetylcholine results in the onset of delirium.
What is the pathophysiology of the cholinergic hypothesis?
Acetylcholine plays an important role in memory and cognition. Therefore, anticholinergic drugs, as well as dopamine agonists which inhibit the effect of cholinergic activity, induce delirium.
What is the support of the cholinergic hypothesis?
- Patients with delirium show reduced brain cholinergic activity
- Dopamine antagonists treat some symptoms associated with delirium
- Many precipitate factors for delirium (hypoxia, hypoglycemia) decreases acetylcholine synthesis in the brain
- High levels of serum anticholinergic activity are associated with an increased risk of delirium
Why is the pathophysiology of delirium poorly understood?
- Inattention and impaired cognition are difficult to define
- Fluctuating course is a hallmark of the disease (again, difficult to define)
- Multiple interacting factors
- Inaccessibility of the CNS to scientific investigation
What are some physical hypotheses for the pathophysiology of delirium?
Physiological stressors (cortisol, hypoxia)
Explain how delirium differs from psychotic disorders, depression and dementia.
Psychotic disorders:
- schizophrenia tends to have gradual onset
- appears late in adolescence/early adulthood
- preceded by a phase of social isolation
- disorientation and LOC fluctuation are rare
Dementia
- clients’ LOC typically intact
- inattention is absent or mild
- rarely exhibit fluctuations in cognitive function
Depression
- more gradual onset of psychomotor slowing
cognitive deficits tend to reflect disinterest as opposed to disorientation
What percentage of delirium cases are preventable?
Estimated 30-40%
What percentage of delirium cases persist after discharge (months to years)?
50%
What is the one year mortality rate of elderly with delirium?
35-40%
What fraction of delirium cases go unreported?
2/3
What are some important lab values to review when considering diagnosis of delirium?
- CBC with differential
- Iron levels (anemia and hypoxia are precipitating factors)
- electrolytes and fluids
- haemoglobin
- serum albumin
- plasma glucose
- no lab test can diagnose, just augment diagnosis
What are some metabolic hypotheses for the pathophysiology of delirium?
- lactic acidosis
- hyper/hypoglycemia
- 1gf1
- hypercapnia
What are some electrolyte hypotheses for the pathophysiology of delirium?
sodium, calcium, magnesium
What are the three categories of pathophysiology disorders for delirium?
- physical
- electrolyte
- metabolic
