Delirium Flashcards
Define delirium.
A sudden (hours to days) disturbance in attention, awareness (falling asleep), and cognition that is not better explained by another neurocognitive disorder
- Cognitive disturbances can be: memory deficit, disorientation, language, visuospatial ability, or perception)
- Delirium is brain dysfunction related to an underlying medical condition, not a primary psychiatric illness
What toxins are often associated with delirium?
History, physical examination, or laboratory findings may demonstrate that the disturbance is a direct physiologicalconsequence of:
- Another medical condition
- Substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication)
- Exposure to a toxin
What are other names of delirium (6)?
1) Acute confusional state
2) Toxic/metabolic encephalopathy
3) Acute brain failure
4) Altered mental status
5) Acute mental status change
6) “Reversible dementia”
What are signs and symptoms of delirium (7)?
1) Altered level of consciousness
- Clouded sensorium
- Fluctuating attention, distractibility
- Can range from hyper-alert to drowsy, stupor, or coma
2) Perceptual disturbances
- Hallucinations, misinterpretations, illusions
- Usually frightening or threatening
3) Delusions, often paranoid
4) Disturbed sleep-wake cycle
5) Change in activity level
6) Emotional disturbances
7) Cognitive disturbances
What are the common emotional disturbances in delirium?
- Affective lability
- Fear
- Anger/irritability
- Tearfulness
What are the common cognitive disturbances in delirium?
- Disorientation to time or place
- Short-term memory impairment
- Incoherent speech
- Impaired naming
- Impaired visuoconstructional ability
- MOCA scores will improve when patients are better
Describe hyperactive delirium.
- Agitation
- Hyper-arousal
- Hallucinations, delusions
- Can be mistaken for primary psychotic disorder
- Sometimes responds to dopamine-blocking agents (e.g. haloperidol)
Describe hypoactive delirium (more common)
- Often mistaken for depression
- Lethargy
- Confusion
- Sedation
- Mixed hyperactive/hypoactive phases can occur in delirium
What is the prevalence of delirium in elderly patients in acute care settings?
Up to 50% of older persons admitted to acute care settings
What is the prevalence of delirium in ICU patients?
Up to 40-87% of patients admitted to ICU
What is the post-operative prevalence of delirium?
Post-operatively:
10-15% of elderly after any surgery/anesthesia
25-35% after cardiothoracic surgery
40-50% after repair of hip fracture
What is the most common cause of delirium in younger adults/children?
Toxic response/abuse
What risk factors are associated with delirium?
Advanced age Pre-existing dementia Medical comorbidity H/o brain injury H/o alcohol abuse Male sex Sensory impairment (vision, hearing) Malnourishment, dehydration
What are the health consequences of delirium?
- Increased length and cost of hospitalization
- Increased nosocomial complications
- Decreased independent living status and increased institutionalization
- Increased risk of death for up to 2 years following discharge
- Worse health outcomes
What does an EEG show in delirium?
EEG shows diffuse slowing
- Generalized dysfunction of cortical and subcortical structures, particularly in non-dominant hemisphere
What is the role of dopamine in delirium?
Excess dopaminergic activity
- Dopaminergic agonists can mimic some symptoms of delirium
- Anti-dopaminergic agents (eg haloperidol) can be effective in treating symptoms of delirium
What is the role of acetylcholine in delirium?
Reduced cholinergic activity
- Anticholinergic medications can cause or exacerbate delirium
- Serum levels of anticholinergic activity are elevated in patients with post-op delirium and correlate with severity of cognitive impairment
- Mixed results for cholinesterase inhibitors
What are other neurotransmitter related subtypes of delirium?
Abnormal GABA, serotonin, histamine, and glutamate levels have been found in various subtypes of delirium
What are causes of delirium? ( I WATCH DEATH)
I: Infections (pneumonia, UTI)
W: Withdrawal
A: Acute metabolic (acidosis, renal failure, electrolyte abnormalities)
T: Trauma (acute severe pain)
C: CNS pathology
H: Hypoxia
D: Deficiencies (vitamin B12, thiamine)
E: Endocrinopathies (thyroid, parathyroid, glucose)
A: Acute vascular (CVA, MI, PE, CHF)
T: Toxins/drugs (prescribed or recreational)
H: Heavy metals
What drugs are associated with delirium?
Opiates Antibiotics Anticholinergic drugs (antihistamines, TCAs) Anticonvulsants Corticosteroids Antineoplastic drugs Antiparkinsonian agents Cardiac drugs, especially antiarrhythmics Benzodiazepines Stimulants
What other conditions should be on the differential diagnosis for delirium?
- Mania
- Schizophrenia
- Dementia
- Depression
- These disorders are NOT generally associated with altered sensorium or fluctuating attention
What questions should be asked when evaluating a patient’s history suspected of delirium?
1) Has the patient been physically ill?
2) Does the patient have underlying cognitive impairment (e.g. dementia)?
3) Is there a history of delirium during previous hospitalizations?
4) Review vital signs for fever, tachycardia, other abnormalities
What parts of the mental status exam should are changed in delirium?
- Appearance and behavior
- Hypervigilant, frightened, psychomotor agitation or retardation, unusual behavior
- Speech
- Incoherent, rambling, slurred
- Mood/Affect
- Labile, tearful, irritable, anxious, angry, apathetic, blunted, despondent, perplexed
- Thought process
- Loose associations, tangential, incoherent
- Thought content
- Paranoia, hallucinations (especially visual), other delusions
- Cognition
- Disorientation, poor attention/concentration, confusion, impaired memory
What questions are asked in the confusion assessment method?
- Acute Onset and Fluctuating Course
- Is there evidence of an acute change in mental status from the patient’s baseline?
- Inattention
- Did the patient have difficulty focusing attention, (e.g. being easily distractible) or having difficulty keeping track of what is said?
- Disorganized Thinking
- Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
- Altered Level of Consciousness
- Overall, how would you rate this patient’s level of consciousness?
- Alert (normal)
- Vigilant (hypervigilant)
- Lethargic (drowsy, easily aroused)
- Stupor (difficult to arouse)
- Coma (unarousable)
- Overall, how would you rate this patient’s level of consciousness?
