Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Psychiatry Part 2 > Delirium > Flashcards

Delirium Flashcards

1
Q

Definition of delirium

A

Neuropsychiatric syndrome (also called acute confusional state or acute brain failure) common agmonst medically ill, often misdiagnosed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

DSM IV criteria for delirium

A
  1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention
  2. A change in cognition or development of perceptual disturbances that is not better accounted for by a preexisting, existed or evolving dementia
  3. The disturbance develops over a short period of time and tends to fluctuate during the course of the day
  4. There is evidence from the history, PE or labs that the disturbance is caused by the physiological consequence of a medical condition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Clinical characteristics of delirium

A
  • Develops acutely (hours to days)
  • Characterized by fluctuating level of consciousness
  • Reduced ability to maintain attention
  • Agitation or hypersomnolence
  • Extreme emotional lability
  • Cognitive deficits can occur
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Cognitive deficits in delirium

A
  1. Language difficulties: word finding difficulties, dysgraphia
  2. Speech disturbances: slurred, mumbling, incoherent or disorganized
  3. Memory dysfunction: marked short-term memory impairment, disorientation to person, place, time
  4. Perceptions: misinterpretations, illusions, delusions and/or visual (more common) or auditory hallucinations
  5. Constructional ability: can’t copy a pentagon
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Types of delirium

A

Hyperactive or hyperalert
Hypoactive or hypoalert
Mixed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Hyperactive or hyperalert delirium

A

Hyperactive, combative and uncooperative
May appear to be responding to internal stimuli
Frequently these patients come to our attention because they are difficult to care for

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Hypoactive or hypoalert delirium

A

Napping on and off throughout day
Unable to sustain attention when awakened, quickly falling back asleep
Misses meals, medications, appointment
Does not ask for care or attention
Easy to miss because caring for these patients is not problematic to staff

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Most common types of delirium

A

Hypoactive and mixed account for ~80% of delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What percent of hospitalized elderly patients >65 y/o get delirium?

A

40%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Delirium etiology

A

Usually multifactorial

  • systemic illness
  • medications (any psychoactive med can cause delirium)
  • presence of risk factors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What systemic illnesses can cause delirium?

A 
Infections
Electrolyte abnormalities
Endocrine dysfunctions (hypo or hyper)
Liver failure (hepatic encephalopathy)
Renal failure (uremic encephalopathy)
Pulmonary disease with hypoxemia
Cardiovascular disease/events: CHF, arrhythmias, MI
CNS pathology: tumors, strokes, seizures
Deficiency states: thiamine, nicotinic or folic acid, B12
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What drugs can cause delirium?

A

Anticholinergics (furosemide, digoxin, theophylline, cimetidine, prednisolone, TCA’s, captopril)
Analgesics (morphine, codeine)
Steroids
Antiparkinson (anticholinergic and dopaminergic)
Sedatives (benzodiazepines, barbiturates)
Anticonvulsants
Antihistamines
Antiarrhythmics (digitalis)
Antihypertensives
Antidepressants
Antimicrobials (penicillin, cephalosporins, quinolones)
Sympathomimetics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the predisposing risk factors for delirium?

A
  • > 60 y/o
  • Male sex
  • Visual impairment
  • Underlying brain pathology (e.g. stroke, tumor, vasculitis, trauma, dementia)
  • Major medical illness
  • Recent major surgery
  • Depression
  • Functional dependence
  • Dehydration
  • Substance abuse/dependence
  • Hip fracture
  • Metabolic abnormalities
  • Polypharmacy
  • Meds
  • Severe acute illness
  • UTI
  • Hyponatremia
  • Hypoxemia
  • Shock
  • Anemia
  • Pain
  • Orthopedic surgery
  • Cardiac surgery
  • ICU admission
  • High number of hospital procedures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What do you have to rule out?

A 
Wernicke’s
Hypoxia
Hypoglycemia
Hypertensive encephalopathy
Meningitis/encephalitis
Poisoning
Anticholinergic psychosis
Subdural hematoma
Septicemia
Subacute bacterial endocarditis
Hepatic or renal failure
Thyrotoxicosis/myxedema
Delirium tremens
Complex partial seizures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Pathophysiology of delirium?

A

Hypotheses:

  • Neurotransmitter abnormalities
  • Inflammatory response with increased cytokines
  • Changes in BBB permeability
  • Widespread reduction in cerebral oxidative metabolism
  • Increased activity of hypothalamic-pituitary-adrenal axis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the most sensitive items in identifying delirium with MMSE?

A

Serial 7’s, orientation, recall memory

- MMSE is not sensitive but can reveal waxing and waning course

17
Q

Difference between delirium and psychiatric disorder?

A 
Clouded consciousness or decreased level of alertness
Disorientation
Acuity of onset and course
Age >40 without prior psych history
Presence of risk factors
18
Q

Dementia vs. Delirium?

A

Dementia: insidious onset, chronic memory and executive function disturbance, intact alertness and attention, impoverished speech and thinking
Delirium: cognitive changes develop acutely and fluctuate, speech can be confused or disorganized, alertness and attention wax and wane

19
Q

Schizophrenia vs. Delirium?

A 
Schizophrenia:
Onset is rare after 50
AH more common than VH
Memory is grossly intact
Disorientation is rare
Speech is not dysarthric
No wide fluctuations over the course of a day
20
Q

Mood disorders vs. Delirium?

A

Mood disorders:
Persistent rather than labile mood with more gradual onset
Mania:
Can be very agitated but cognitive performance is not usually as impaired
Flight of ideas usually have some thread of coherence unlike simple distractibility
Disorientation is unusual

21
Q

Treatment for delirium?

A

Treat the UNDERLYING CAUSE
Environmental interventions
Minimize psychoactive medications

22
Q

What do antipsychotics help with in delirium?

A

Decrease psychotic symptoms, confusion, and agitation

23
Q

What is the first line treatment for delirium?

A

IV Haldol
Onset within 5-20 minutes
Can transition to BID or QHS oral dose and taper

24
Q

Which atypical antipsychotics now have supporting data for use in delirium?

A

Risperdal 0.5-2 mg
Quetiapine 12.5-50 mg
Olanzapine 2.5-10 mg

25
Q

Course and prognosis of delirium?

A

Most symptoms resolve within a week of correction/improvement of underlying etiology but some may wax and wane
Can take weeks in some patients
Some (esp. older) may never return to baseline

26
Q

Case #1
71 y/o M with hx of asthma, BPH, and HTN admitted for bilateral LE cellulitis
Over 24 hrs became confused, agitated, uncooperative, and somnolent
Appears to be talking to someone in his room when no one is there
No psych hx, drinks 1-2 wine glasses per night
Meds: lisinopril, naproxen, cimetadine, albuterol/ipratropium inhaler, levofloxacin, O2 NC

A

What points to delirium?

  • altered mental status over short period of time
  • alternating agitation, confusion, somnolence
  • AH in 70 y/o without psych hx

Medical possibilities?

  • Meds
  • Hypoxia
  • Cellulitis
  • Stroke (hx of HTN)
  • UTI (hx of BPH)
  • Metabolic abnormalities
  • EtOH w/drawal
27
Q

Case #2
83 y/o with hx of HTN, DM with neuropathy, occasional angina admitted for failure to thrive
Missed his bridge game for 1st time in 12 yrs
Difficult to arouse
Minimally communicative, incontinent, hasn’t eaten in days
Was hyponatremic with UTI and treated but remains somnolent and withdrawn
Meds: insulin, atenolol, lisinopril, temazepam, azithromycin, aspirin
Monosyllable answers, poor eye contact, 9/30 on MMSE

A

Hypoactive delirium BUT:

  • Urinary incontinence with altered mental status = pressure hydrocephalus?
  • DM, HTN = stroke or fall? needs head CT
  • Meds?
  • Check blood sugars
  • Do urine tox screen
  • Depressed? Demented?
  • Low MMSE could signal inattention or depression
28
Q

What percent of post-hip fracture patients get delirium?

A

50%

29
Q

What percent of patients in the surgical ICU get delirium?

A

30%

30
Q

What percent of patients on general medical wards get delirium?

A

20%

31
Q

What percent of patients on general surgical wards get delirium?

A

15%

32
Q

What are the tests of attention?

A

Serial 7’s, spelling WORLD backwards, months of the year backward, counting down from 20

33
Q

What is the main advantage of giving haloperidol IV?

A

Significantly reduced risk of EPS

Psychiatry Part 2 (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions