delirium Flashcards
DSM5 criteria for delirium
1- disturbance in attention and awareness
2- disturbance develops over short period of time and fluctuates in severity during the course of a day
3- additional disturbance in cognition or perception
4- not better explained by another preexisting or evolving NCD
5- is a direct physiological consequence of general medical condition, substance, or withdrawal
synonyms for delirium
altered mental status, encephalopathy, ICU psychosis, acute brain failure, acute confusional state, acute reversible psychosis
motor subtypes of delirium
hypoactive (often missed/ confused with depression)- dec activity, lethargy, apathy
hyperactive- inc activity, delusions, hyper-alert
mixed
risk factors for delirium
elderly (dec ACh, vascular changes)
CNS d/o (major/minor NCD)
multiple meds (esp anti-ACh)
infancy-childhood- more than early-middle adulthood, may be related to febrile illness and meds (anti-ACh)
burn pts, low serum albumin, EtOH/drug dependency, hearing/visual deficits
clinical features of delirium
abrupt/ acute onset (days), fluctuation in sx severity (worse at night, hard to dx)
diffuse cognitive impairment (attention, memory, disorientation to time/place, executive dysfunction)
thought disturbance, language disturbance, perceptual disturbance (including hallucination, visual»_space; aud)
psychomotor abnormalities, sleep-wake disturbance, delusion, affective lability, neurologic abnormalities (myoclonic jerking)
pathophysiology/ NTs involved in delirium
ACh- dec -> information processing/memory prob, arousal, attention/focus
DA- agonists may induce delirium, antagonists may treat
cytokines- implicated in delirium d/t tissue destruction, infection, inflammation
etiology of delirium
commonly: general medical condition, meds, substance intoxication or withdrawal, multiple
fecal impaction, urinary retention, uncontrolled pain
urgent etiologies of delirium
I WATCH DEATH:
Infections (sepsis, meningitis, pneumonia, UTI, indwelling catheter)
Wernicke’s/ Withdrawal (EtOH, sedative hypnotics, barbs)
Acute metabolic (hepatic/renal/pulm insufficiency, fluid/electrolye imbalance)
Trauma/burn/ recent surgery
CNS (epilepsy, neoplasm, head trauma, ischemic vascular dz)
Hypoxia/ hypercapnia
Deficiency (thiamine, B12, folate, malnourishment)
Endocrine (hypo/hyper-thyroid, hypo-pit or -glycemia)
Acute vascular/bleed
Toxin/meds (steroids, antimicrobial)
Heavy metals
life-threatening etiologies of delirium
WHIMPS: Wernicke’s/ withdrawal (EtOH, BZDs), Hypoglycemia/ Hypoxia/ HTN crisis, Infection/ Intracerebral bleed, Metabolic derangement/ Meningitis, Poison, Seizure
EEG findings in delirium
usually diffuse theta/delta waves (“slowing”), poorly organized background rhythm
low voltage fast activity in EtOH or sedative-hypnotic withdrawal
tx of delirium
1- identify and reverse reason for delirium- tx underlying dz or contributing factors
2- reduce psychiatric/ behavioral sx- manipulate meds (anti-psychotics, cholinesterase inh, BZDs) and environment (avoid sleep interruption, close to nurse, clocks/calendar, good lighting, sensory aids)
typical antipsychotics for delirium
low potency not recommended
DOC: haloperidol bc no anti-ACh, little risk hypoTN, no resp suppression, little cardiotoxicity, fast acting
ADR: EPS, hypoTN (usually d/t volume depletion), rare QT prolongation
atypical antipsychotics for delirium
quetiapine, risperidone, olanzapine, ziprasidone, arirpiprazole
theoretically lower risk EPS, still risk of QT prolongation
cholinesterase inhibitors for delirium
physostigmine: dx tool for anti-ACh toxicity, rarely needed for tx
BZDs for delirium
most appropriate for EtOH or sedative-hypnotic withdrawal, otherwise risk of disinhibition and resp depression > benefits
*potential adjunct tx to anti-psychotics
