DELIRIUM

Question 1

what is the DSM-V definition of delirium?

Answer 1

disturbance in consciousness/attention/awareness AND disturbance in cognition.

develops over hours to days; can fluctuate.

evidence of medical condition, substance intoxication/withdrawal, or med side effect

Question 2

delirium is also known as ?

Answer 2

encephalopathy.
acute confusional state.

Question 3

what are the etiologies of delirium?

Answer 3

drug/alcohol intoxication/withdrawal.
med side effects.
seizure.
stroke.
metabolic disturbance (electrolyte imbalance, hypo/hyperglycemia, organ failure).
sleep deprivation.
infection.

Question 4

what is the pathogenesis of delirium?

Answer 4

poorly understood.
possibly acetylcholine deficiency (anticholinergic drugs can cause delirium, and reverses with cholinesterase inhibitors [physostigmine])

Question 5

what are risk factors for delirium?

Answer 5

underlying brain disease (Dementia [superimposed in 22-89%], stroke, parkinson’s disease)
advanced age.
sensory impairment.

Question 6

what is the clinical presentation of delirium?

Answer 6

Disturbance of consciousness
- distractibility*****
- tangential or disorganized speech
- drowsy, lethargic, or semi-comatose (except in case of alcohol/sedative drug withdrawal, in which case pt will be hypervigilant)

*Disturbance of cognition
- decrease in level of functioning
- (dementia can impair cognitive ability and frequently underlies delirium)
- perceptual disturbance (misidentifies people/objects, can have vague delusions of harm, hallucinations)
- language difficulties (may lose second language)
- language difficulties

Question 7

what is the hallmark of the clinical presentation of delirium?

Answer 7

distractibility

Question 8

what are some medications you should check for when assessing a pt you believe to have delirium?

Answer 8

antihistamines, benzos, TCAs, sleeping aids, opioids, neuroleptics, corticosteroids, H2 blockers (cimetidine, ranitidine), Parkinson drugs (levodopa, amantadine)

Question 9

when is it NOT necessary to do imaging when a pt presents with sx of delirium?

Answer 9

not necessary when there is an obvious treatable medical problem, no evidence of trauma, no new focal neuro signs, AND pt is arousable and able to follow simple commands

Question 10

when should you do imaging when a pt presents with sx of delirium and what kind of imaging should be done?

Answer 10

when cause of delirium is unknown OR pt does not improve as expected following treatment of a known cause&raquo_space; order head CT&raquo_space; if negative, order MRI

Question 11

should you perform a lumbar puncture on a pt presenting with delirium? if so, when?

Answer 11

mandatory if cause of delirium is still unknown after CT and especially if pt is febrile.

Question 12

when a pt presents with delirium, what are some diagnoses that an EEG can rule in/out?

Answer 12

can rule out seizures.
can confirm diagnosis of metabolic or infectious encephalopathies.

Question 13

pt presents with confusion, ataxia, and opthalmoplegia (horizontal nystagmus) - what is the most likely diagnosis?

Answer 13

symptom triad of wernicke’s encephalopathy

Question 14

what is the cause of wernicke’s encephalopathy?

Answer 14

thiamine deficiency, most commonly due to alcoholism

Question 15

what is the treatment for Wernicke encephalopathy?

Answer 15

IV thiamine

Question 16

describe korsakoff syndrome

Answer 16

“chronic” wernicke’s encephalopathy + anterograde and retrograde amnesia with confabulation

Question 17

what is the trx for delirium?

Answer 17

identify and trx the underlying cause of the delirium