Delirium Flashcards
Prognosis of geriatric delirium
increased mortality in hospital/2 years post
increased morbidity
more cognitive deficits: up to 30-60% at 1 month
lingering impairment at 6 months post-cardiac surgery
less likely to achieve pre-delirium cognitive/functional baseline status, longer course of delirium
Independent risk factor to mortality/morbidity in and after hospitalization
persistent cognitive/functional deficits common in geriatric delirium
GA may lead to lingering cognitive impairments (POCD)
Delirium DSM5 criteria
A: disturbance in attention and awareness
B: develops over a short period of time, tends to fluctuate in severity during the day
C: additional disturbance in cognition
D: Disturbances in A/C are not better explained by another disorder
E: evidence that disturbance is a direct physiological consequence of another general medical condition
Hyperactive delirium
agitate
differentiate from anxiety, dementia
Hypoactive delirium
apathetic
differentiate from depression
less sleep-wake reversal
Delirium clinical features
Poor attention/vigilance Clouding of consciousness DIsorientation Diffuse cognitive impariment Poor memory Delusions Perceptual changes/hallucinations Language disorder Disorganized thinking/thought disorder mood lability sleep disturbances psychomotor changes
Diagnostic process of geriatric delirium
24 hour observation including sleep-wake anxiety new incontinence unsteady gait, falls dysarthria/incoherence mood/affect lability subtle paranoia and hypervigilance sleep disturbance - vivid dreams/nightmares!!
Subjective experience of delirium
“Being in a dream”
mental content more related to internal fantasy than external reality
passive
timelessness, sequence loss
loss of “self-consciousness”
loss of self-reflective awareness
Losso f appraisal of self to environment by drawing upon experience in memory
Retrospectively viewed as distressing usually, if recalled
may lead to anxiety, paranoia, and even PTSD
Screening for delirium
under-recognized esp in those >80 with hypoactive delirium with visual impairment and/or pre-existing dementia
NO reliable screening tool to differentiate delirium and dementia
practically: look for acute-onset/fluctuation in cognition, behaviour, etc.
Confusion Assessment Method
Acute onset and fluctuation AND inattention AND disorganized thinking OR altered LOC excellent sensitivity, good specificity
Pathophysiology of delirium general
Hypotheses: oxygen deprivation NT dysfunction inflammation and cytokines Physiologic stress on BBB/HPA
Generalized cortical disturbance in delirium
reduced cerebral oxidative metabolism/blood flow
Electroencephalographic showing:
- decreased alpha (fast) waves
- increased slow waves - theta, delta
degree of slowing correlates with severity of cognitive dysfunction (except alcohol withdrawal)
Delirium tremens cortical activity
alcohol withdrawal
increased cerebral metabolism
increased noradrenergic response
EEG: low to moderate voltage fast activity
Cortical arousal in delirium
Reticular activating system: ACh, NE, 5HT
Hypothalamus: his
Basal forebrain: ACh
Autonomic arousal in delirium
Sympathetic output (NE) - increased in delirium tremens
Neurochemical dysfunction in delirium
ACh: anticholinergic can induce delirium, reversed by physostigmine
DA: dopamine agonists can induce delirium - antipsychotics can treat
NE increased
?GABA decreased
?Serotonin, histamine
?Glutamate increased
Delirium Tremens clinical features
cessation/reduction in heavy use of alcohol
>=2 features developing within several hours - few days:
- autonomic hyperactivity
- increased hand tremor
- insomnia
- nausea/vomiting
- transient hallucinations/illusions: usually visual, may be auditory (Lilliputian hallucination)
- psychomotor agitation
anxiety
- grand al seizures
Watch for concurrent medica lillness
Alcohol withdrawal time course
Symptoms within:
12-24 h for withdrawal
24-48 seizures
72-96 delirium tremens
CIWA-Ar
delirium tremens screening N/V Headache Anxiety Paroxysmal sweats tremors agitation disorientation/clouding of sensorium visual disturbances tactile disturbances auditory disturbances
Delirium vs dementia
onset
attention usually intact in dementia
fluctuation seen in delirium
EEG markedly slowed in delirium (except alcohol)
Delirium vs depression
insight often present in depression
Delirium vs Lewy Body Dementia
infrequent symptom fluctuation
parkisonism/neuroleptic sensitivity frequently seen in LBD
Differential diagnosis of memory loss
Gradual onset with functional impairment> Dementia
Stepwise, sudden deterioration in cognition, slurred speech, confusion, aphasia, focal weakness: Cerebrovascular disease
Acute cognitive impairment: delirium
Complains of memory loss, decreased concentration, feeling of hopelessness: depression
Clinical features of behavioural variant FTD
character change and disordered social conduct features intially and throughout disease course
Instrumental functions of perception, spatial skills, praxis, memory intact/relatively well-preserved
FTD core diagnostic features
insidious onset, gradual progression
early decline in social interpersonal conduct
early impairment in regulation of personal conduct
early emotional blunting
early loss of insight
Behavioural supportive diagnostic features of FTD
decline in personal hygiene mental rigidity, inflexibility distractibility, impersistence hyperorality, dietary changes perseverative and stereotyped behaviour utilization behaviour
Physical supportive diagnostic features of FTD
primitive reflexes
incontinence
akinesia, rigidity, tremor
low and labile BP
Speech and language supportive diagnostic features of FTD
altered speech output - aspontaneity/economy of speech, pressure of speech stereotypy of speech echolalia perseveration mutism
Investigations of FTD
Neuropsychology: significant impariment on frontal lobe tests in absense of severe amnesia, aphasia, or perceptuospatial disorder
Electroencephalopathy: normal on conventional EEG despite clinically evident dementia
Brain imaging: predominant frontal and/or anterior temporal abnormality
Predisposing factors of geriatric delirium
cognitive impariment sleep deprivation immobility visual/hearing impariment dehydration
DDx of causes of delirium
DIMS-R Drugs Infection Metabolic disturbances Structural insults Retention problems
Drug causes of delirium
prescribed (narcotics, steroids, anticholinergics, NSAIDs)
OTC (dimenhydrinate, diphenhydramine)
drug intoxication/withdrawal (alcohol, sedative-hypnotics, narcotics
Infectious causes of delirium
urinary tract, lungs, skin blood
Metabolic causes of delirium
fluid (dehydration, hypovolemia)
electrolyte disturbances
nutrition (malnutrition, thiamine deficiency, anemia)
Structural causes of delirium
CV (angina, infarction, CHF)
CNS( stroke/ischemia, concussion)
pulmonary (hypoxia, e.g. COPD)
GI (bleeding with anemia, C. diff, colitis)
Retention causes of delirium
Urinary
constipation
Reducing the medication load in delirium
Discontinuing/substituting anticholinergic medications
- benadryl, gravol, hydroxyzine
benztropine
Urinary anticholinergics
AVOID amitriptyline - nortriptyline better tolerated
Avoid cimetidine in elderly
Monitor effects of steroids
Switch narcotics to: hydromorphone, oxycodone, fentanyl
Non-pharmacologic measures of delirium management
Minimize use of: - physical restraints - catheters - room transfers Maintain adequate nutrition, hydration Optimize sensory input maintain orientation decrease enviornmental stimuli increase mobility earlier consider family/1:1 sitter detect, manage pain
Physical restraints and delirium
Restraints necessary to prevent morbidity?
BUT can increase risk of developing delirium by 4.4 x
Additional morbidities/mortality risk
Avoid limb restraints in frail elderly!
Perpetuating factors of delirium in long-term care
Severity predicted by: Absence of: - reading glasses - aids to orientation - family member - glass of water Presence of bed rails/otehr restraints prescription of >=2 new meds
Practical tips in delirium
ask specifically about vivid dreams/nightmares visual/hearing aids optimize sensory input carry voice amplifier urinary retention/bladder scanner
