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Psych Block 2 > Delirium > Flashcards

Delirium Flashcards

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1
Q

Define delirium.

A

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
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2
Q

What toxins are often associated with delirium?

A

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
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3
Q

What are other names of delirium (6)?

A

1) Acute confusional state
2) Toxic/metabolic encephalopathy
3) Acute brain failure
4) Altered mental status
5) Acute mental status change
6) “Reversible dementia”

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4
Q

What are signs and symptoms of delirium (7)?

A

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

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5
Q

What are the common emotional disturbances in delirium?

A
  • Affective lability
  • Fear
  • Anger/irritability
  • Tearfulness
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6
Q

What are the common cognitive disturbances in delirium?

A
  • Disorientation to time or place
  • Short-term memory impairment
  • Incoherent speech
  • Impaired naming
  • Impaired visuoconstructional ability
  • MOCA scores will improve when patients are better
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7
Q

Describe hyperactive delirium.

A
  • Agitation
  • Hyper-arousal
  • Hallucinations, delusions
  • Can be mistaken for primary psychotic disorder
  • Sometimes responds to dopamine-blocking agents (e.g. haloperidol)
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8
Q

Describe hypoactive delirium (more common)

A
  • Often mistaken for depression
  • Lethargy
  • Confusion
  • Sedation
  • Mixed hyperactive/hypoactive phases can occur in delirium
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9
Q

What is the prevalence of delirium in elderly patients in acute care settings?

A

Up to 50% of older persons admitted to acute care settings

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10
Q

What is the prevalence of delirium in ICU patients?

A

Up to 40-87% of patients admitted to ICU

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11
Q

What is the post-operative prevalence of delirium?

A

Post-operatively:
10-15% of elderly after any surgery/anesthesia
25-35% after cardiothoracic surgery
40-50% after repair of hip fracture

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12
Q

What is the most common cause of delirium in younger adults/children?

A

Toxic response/abuse

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13
Q

What risk factors are associated with delirium?

A 
Advanced age
Pre-existing dementia
Medical comorbidity
H/o brain injury
H/o alcohol abuse
Male sex
Sensory impairment (vision, hearing)
Malnourishment, dehydration
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14
Q

What are the health consequences of delirium?

A
  • 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
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15
Q

What does an EEG show in delirium?

A

EEG shows diffuse slowing

- Generalized dysfunction of cortical and subcortical structures, particularly in non-dominant hemisphere

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16
Q

What is the role of dopamine in delirium?

A

Excess dopaminergic activity

  • Dopaminergic agonists can mimic some symptoms of delirium
  • Anti-dopaminergic agents (eg haloperidol) can be effective in treating symptoms of delirium
17
Q

What is the role of acetylcholine in delirium?

A

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
18
Q

What are other neurotransmitter related subtypes of delirium?

A

Abnormal GABA, serotonin, histamine, and glutamate levels have been found in various subtypes of delirium

19
Q

What are causes of delirium? ( I WATCH DEATH)

A

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

20
Q

What drugs are associated with delirium?

A 
Opiates
Antibiotics
Anticholinergic drugs (antihistamines, TCAs)
Anticonvulsants
Corticosteroids
Antineoplastic drugs
Antiparkinsonian agents
Cardiac drugs, especially antiarrhythmics
Benzodiazepines
Stimulants
21
Q

What other conditions should be on the differential diagnosis for delirium?

A
  • Mania
  • Schizophrenia
  • Dementia
  • Depression
  • These disorders are NOT generally associated with altered sensorium or fluctuating attention
22
Q

What questions should be asked when evaluating a patient’s history suspected of delirium?

A

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

23
Q

What parts of the mental status exam should are changed in delirium?

A
  • 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
24
Q

What questions are asked in the confusion assessment method?

A
  1. Acute Onset and Fluctuating Course
    • Is there evidence of an acute change in mental status from the patient’s baseline?
  2. Inattention
    • Did the patient have difficulty focusing attention, (e.g. being easily distractible) or having difficulty keeping track of what is said?
  3. 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?
  4. 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)
25
Q

What labs are done in a patient suspected of delirium?

A
  • Laboratory evaluation
    • CBC, electrolytes, BUN, creatinine, glucose, calcium, magnesium, phosphorus, LFTs
    • Other labs as indicated by history (eg blood cultures if febrile)
    • UA, culture and sensitivity
  • CXR
  • EKG
26
Q

What labs/tests should be done based on a significant history in a patient suspected of delirium?

A 
If indicated by history:
Drug of abuse screen
Serum levels of medications
Ammonia
HIV
CT or MRI of brain
EEG
LP
27
Q

What is the major treatment for delirium?

A

Definitive treatment is treatment of underlying medical illness

28
Q

What behavioral treatments are necessary in delirium?

A

Orienting stimuli (clocks, calendars, TV/radio)

Support regular sleep-wake cycle

Eyeglasses and hearing aids when indicated

Mobilize patient as soon as possible

Ensure adequate nutrition

Educate and support family

Restraints only when absolutely necessary for safety

29
Q

What are common pharmacologic treatments for delirium?

A 
-  Typical antipsychotic
   Haloperidol (low dose, IV/IM/PO)
- Atypical antipsychotics => less available in parenteral forms
   - Risperidone 
   - Olanzapine 
   - Quetiapine 
- Non-benzodiazepine anxiolytics
   - Trazodone
   - Gabapentin
30
Q

What meds should be avoided in delirium?

A

Avoid benzodiazepines

  • Lorazepam best choice, available PO/IM/IV and has no active metabolites
  • Unless cause of delirium is alcohol or benzodiazepine withdrawal => then use benzodiazepines

Psych Block 2 (22 decks)

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