Delirium Flashcards
Be able to recognize the clinical characteristics of delirium
normal in morning, have a normal and rational conversation with you, and then several hours later they don’t know where they are, hallucinating, and pulling out IV lines
flucuate during the day, confused, hard to focus or concentrate on anything
Learn what is involved in the workup of delirium
want to get a good history:
talking to patient
spouse, old records, etc
what is their baseline normally like (confused, then they’ll be confused, if college grad working on paper, it’s probably not normal baseline)
are they on medications
drugs, vital signs, physical signs that might be symptomatic of another disease
for what it’s worth ICU psychosis, sun down effect, etc:
all mean the exact same thing: delirium, that’s it, plain and simple
82 year-old male with a history of probable Alzheimer’s disease, CAD, and DM has been admitted from a nursing home for worsening confusion and behavioral problems. The nursing personnel at the NH report that the symptoms have become progressively worse since he began having problems sleeping 3 days ago.
Attempts to examine the patient upon arrival to the floor are complicated by his attempts, as he eloquently states, to “Knock you on your ass!”
Review of the medical records from the ED report similar behavior and reports of “seeing things.” He was given lorazepam prior to the CT of his head. He slept through the CT, which only showed atrophy and white matter disease, but is now quite awake and potentially dangerous.
Since the patient is presently being slightly less than cooperative with your attempts to gather a history you collect collateral information…
Although he has some baseline memory problems his current state represents an acute change
His behavior tends to be worse at night when he does not sleep and is more confused and sometimes suspicious
The nurse reports that he is doing better now that she has given him some ice cream, she wonders if you would like to complete your history now…
You identify the fact the patient is disorientated to place and time
He is easily distracted by events in the hall and can not concentrate on your questions
When he attempts to answer your questions he has trouble finding the right words and staying on question
With your diagnosis of delirium you set out to determine potential etiologies of this dangerous condition
Review of the NH records reveal…
Recent discontinuation of donepezil (Aricept) secondary to worsening dementia
Diphenhydramine (Benadryl) was started 3 days ago to help him get some sleep
Chronic digoxin therapy
Chronic urinary incontinence without mention of dysuria
Most recent labs (CBC and BMP performed 6 months ago) were grossly normal
must rule out delirium: if you can treat the underlying cause, then the delirium will get better (broad group of conditions)
Delirium has ____ onset, _____ fluctuate, ______, lasts _______, consciousness _____, _____ alertness, attention and orientation are ______
acute, tends to fluctuate, hours to days, reduced consciousness, increased or decreased alertness, attention and orientation are imparied
hypoactive delirium
1/3 of patients, nice and pleasant, see social cue and nod, act nice, and if you ask them anything else, they’ll tell you it’s 1963 and JFK is president
why is it important to treat delirium?
people die! mortality rate goes way up, and 25-33% of people die within first 3 months, 40-50% within 1 year (considered a medical emergency)
difference between psychosis and delirium:
psychosis is NEVER fatal- they may think there are aliens coming to get them, but they can understand the time and place. Delirium is OFTEN fatal- they will NOT be oriented to time and place
medications that are _____ can cause ________
anticholinergic drugs, delirium to get worse (especially if several drugs with anticholinergic effects are combined: benedryl and tylonol pm can also be anticholinergic)
TEST: the pathophisiology of delirium can be boiled down to:
dopamine excess, and acetycholine deficiency
causes of delirium mnemonic
iwatchdeath infection withdrawl acute metabolic trauma CNS pathology Hypoxia Deficiencies (vitamin B12, folate, thiamine) Endocrinopathies: hyper/hypoglycemia A: Hypertensive encephalopathy, stroke Toxins/drugs: medications illicit drugs, pesticides, etc Heavy metals: lead, mercury, magnesium
mnemonic for life threatening delirium emergencies:
WHHHHIMP wenicke's encephalopathy/withdrawl hypoxia hypertensive encepholopathy Hypoglycemia Hypoperfusion Intracranial bleeding/infection meningitis/encephalitis poisons/medications
there are some medications that can lead people to delirium more so than others
opiates, pain medicine, sedative hypnotics like benzodiazapines (lead to confusion)
delirium can be caused by UTI and first step to treatment is:
treat the underlying cause!!!
then with taking away benzos and possibly use haloperidol (antipsychotic) then provide family cues to orient the person
delirium can be caused by UTI and first step to treatment is:
treat the underlying cause!!!
then with taking away benzos and possibly use haloperidol (antipsychotic) then provide family cues to orient the person
one potential cause of delirium (esp in the elderly) is if they’re taking:
This should also be considered along with the possibility of:
benedryl of tylonol pm; these have anticholinergic properties and when taken with other medicatinos they can cause a great deficiency in ACh, leading to delirium
UTI or dysuria
13 of the 25 most frequently prescribed drugs in geriatric medical practice have anticholinergic effects. ______. Some of these drugs (eg, digoxin) may be difficult to avoid, but the _______from their use in combination puts the patient at risk of delirium and other ________
13 of the 25 most frequently prescribed drugs in geriatric medical practice have anticholinergic effects. synergistic effect,
anticholinergic effects
13 of the 25 most frequently prescribed drugs in geriatric medical practice have anticholinergic effects. ______. Some of these drugs (eg, digoxin) may be difficult to avoid, but the _______from their use in combination puts the patient at risk of delirium and other ________
13 of the 25 most frequently prescribed drugs in geriatric medical practice have anticholinergic effects. synergistic effect,
anticholinergic effects
64 yr old with CAD and no prior psychiatric history who experienced visual hallucinations, paranoia, and fluctuation of attention and awareness on the evening of postoperative day number three following CABG. On examination later that night, the patient is oriented to person, place, and situation, but not to time. Otherwise, his mental status examination and physical examination are essentially unremarkable
delirium
next: find the CAUSE of the delirium by reviewing the medical record, performing focused history and physical examination, and obtaining clinically guided laboratory and imagine studies
71 yr old woman with history of early AD is brought to hospital bc she “just isn’t acting like her normal self” On mental status exam, she is lethargic, easily distractable, and oriented only to peson. At baseline, she is oriented to person and place, but has difficulty recalling the date and time. Physical examination and diagnostic workup are suggestive of an uncomplicated urinary tract infection (UTI). What is the most important component of treating this patient’s delirium?
treat her UTI with antibiotics
the most important component of delirium treatment is to:
detect and treat the precipitating factor. In this case, the patient’s dementia predisposes her to delirium, while the acute onset of the UTI precipitated her change in mental status. Of note, all antibiotics have the potential to contribute to the worsening of delirium, so a change in medication may be necessary if the patient needs prolonged use. Also, antipsychotics can increase mortality
71 yr old woman with history of early AD is brought to hospital bc she “just isn’t acting like her normal self” On mental status exam, she is lethargic, easily distractable, and oriented only to peson. At baseline, she is oriented to person and place, but has difficulty recalling the date and time. Physical examination and diagnostic workup are suggestive of an uncomplicated urinary tract infection (UTI).
Which feature most distinguishes her delirium from AD?
decreased attention
disorientation
cognitive deficits
behavioral disturbances
decreased attention
both delirium and dementia can result in behavioral disturbances, cognitive deficits, and poor orientation. However, in all cases of delirium there is an alteration in level of attention. In early dementia, attention and concentration are typically maintained
