Delirium

Question 1

delirium is characterized by disturbed _____ with decreased ____ and _____ awareness

Answer 1

disturbed consciousness
decreased attention
environmental awarness

Question 2

does delirium come on rapidly or gradually? is it persistent throughout the day?

Answer 2

comes on rapidly

fluctuates throughout the day

Question 3

what does the prodromal phase of delirium often look like?

Answer 3

fatigue, daytime somnolence, decreased concentration, irritability, restlessness, anxiety, mild cognitive impairment

Question 4

does a patient with delirium ever have periods of lucidity?

Answer 4

yes! periods of lucidity where the patient can function at baseline

Question 5

what time of day is delirium worst?

Answer 5

night

Question 6

delirium is often associated with these four features

Answer 6

1) language difficulties (slow or slurred, word finding difficulties)
2) impaired memory
3) disorientation
4) hallucinations (visual, auditory, tactile)

Question 7

what are the 3 clinical variants of delirium?

Answer 7

1) hyperactive
2) hypoactive
3) mixed

Question 8

what two features MUST be included in the confusion assessment method (CAM)?

Answer 8

feature 1 = acute onset, fluctuating course

feature 2 = inattention (is pt having difficult keeping track of what’s been said?)

Question 9

in addition to feature 1 and 2, ONE of these two features must be present to confirm dx of delirium

Answer 9

feature 3 = disorganized thinking (rambling, unclear)

feature 4 = altered level of consciousness (hyperalert, lethargic, stupor, etc)

Question 10

which medications have the propensity to precipitate delirium?

Answer 10

1) anticholinergics
2) anti-inflammatories
3) benzos (use or withdrawal)
4) ETOH (withdrawal)
5) CV meds – digoxin, diuretics
6) lithium
7) opioid antagonists

Question 11

in terms of GI/GU, what do we worry about that could precipitate delirium?

Answer 11

constipation/fecal impaction or post-op urinary retention

Question 12

what is the in-hospital mortality rate of delirium?

Answer 12

25-33 percent

similar to sepsis

Question 13

approximately ____ percent of medical patients experience delirium at some point during hospitalization

Answer 13

30 percent

Question 14

financially, why do we worry about delirium?

Answer 14

costs billions of dollars in yearly healthcare costs in US

Question 15

patient has acute episode of delirium in the hospital, where are they most likely to go after this?

Answer 15

nursing home

Question 16

does one episode of delirium put you at risk for more?

Answer 16

yes

Question 17

______ often goes unrecognized prior to the onset of delirium

Answer 17

dementia

Question 18

what neurotransmitter is thought to play a critical role in delirium?

Answer 18

acetylcholine

Question 19

what are the 3 pharmacologic or physiologic processes that decrease ACH synthesis, leading to delirium?

Answer 19

1) anticholinergic drugs = decrease ACH
2) hypoxia, hypoglycemia, thiamine deficiency = decrease ADH synthesis
3) alzheimer’s characterized by loss of cholinergic neurons (risk of delirium)

Question 20

what are the two components that give way to an episode of delirium?

Answer 20

1) insult to vulnerable brain
2) underlying neurodegenerative disorder

therefore – delirium sometimes brings out previously unrecognized dementia or other brain disorders

Question 21

when do we consider pharmacologic therapy in delirium?

Answer 21

ONLY when patient is at risk for harming him/herself

Question 22

what is the DOC in delirium?

Answer 22

haloperidol

Question 23

what do you need to monitor while patient is on haloperidol?

Answer 23

QTc prolongation

Question 24

if patient has been on haldol for a week, what do you need to do?

Answer 24

switch to other antipsychotic agent to avoid extra-pyrimidal symptoms

Question 25

quetiapine (seroquel) is the DOC for delirium in these 4 populations

Answer 25

1) lewy body dementia
2) parkinsons dementia
3) AIDS-related dementia
4) HX of EPS

Question 26

what do we do if delirium is due to ETOH or benzo withdrawal?

Answer 26

give benzos titrated to effect

Question 27

what are the 2 things we do during ETOH withdrawal? (one is a tool, one is a med in addition to benzos)

Answer 27

1) CIWA

2) thiamine to avoid wernicke’s

Question 28

should we restrain patients who are becoming agitated or aggressive?

Answer 28

NO – can precipitate delirium

Question 29

is delirium reversible?

Answer 29

yes! potentially, but may require weeks or months to fully resolve