Delirium

Question 1

Be able to recognize the clinical characteristics of delirium

Answer 1

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

Question 2

Learn what is involved in the workup of delirium

Answer 2

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

Question 3

for what it’s worth ICU psychosis, sun down effect, etc:

Answer 3

all mean the exact same thing: delirium, that’s it, plain and simple

Question 4

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

Answer 4

must rule out delirium: if you can treat the underlying cause, then the delirium will get better (broad group of conditions)

Question 5

Delirium has ____ onset, _____ fluctuate, ______, lasts _______, consciousness _____, _____ alertness, attention and orientation are ______

Answer 5

acute, tends to fluctuate, hours to days, reduced consciousness, increased or decreased alertness, attention and orientation are imparied

Question 6

hypoactive delirium

Answer 6

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

Question 7

why is it important to treat delirium?

Answer 7

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)

Question 8

difference between psychosis and delirium:

Answer 8

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

Question 9

medications that are _____ can cause ________

Answer 9

anticholinergic drugs, delirium to get worse (especially if several drugs with anticholinergic effects are combined: benedryl and tylonol pm can also be anticholinergic)

Question 10

TEST: the pathophisiology of delirium can be boiled down to:

Answer 10

dopamine excess, and acetycholine deficiency

Question 11

causes of delirium mnemonic

Answer 11

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

Question 12

mnemonic for life threatening delirium emergencies:

Answer 12

WHHHHIMP
wenicke's encephalopathy/withdrawl
hypoxia
hypertensive encepholopathy
Hypoglycemia
Hypoperfusion
Intracranial bleeding/infection
meningitis/encephalitis
poisons/medications

Question 13

there are some medications that can lead people to delirium more so than others

Answer 13

opiates, pain medicine, sedative hypnotics like benzodiazapines (lead to confusion)

Question 14

delirium can be caused by UTI and first step to treatment is:

Answer 14

treat the underlying cause!!!

then with taking away benzos and possibly use haloperidol (antipsychotic) then provide family cues to orient the person

Question 15

delirium can be caused by UTI and first step to treatment is:

Answer 15

treat the underlying cause!!!

then with taking away benzos and possibly use haloperidol (antipsychotic) then provide family cues to orient the person

Question 16

one potential cause of delirium (esp in the elderly) is if they’re taking:

This should also be considered along with the possibility of:

Answer 16

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

Question 17

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 ________

Answer 17

13 of the 25 most frequently prescribed drugs in geriatric medical practice have anticholinergic effects. synergistic effect,
anticholinergic effects

Question 18

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 ________

Answer 18

13 of the 25 most frequently prescribed drugs in geriatric medical practice have anticholinergic effects. synergistic effect,
anticholinergic effects

Question 19

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

Answer 19

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

Question 20

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?

Answer 20

treat her UTI with antibiotics

Question 21

the most important component of delirium treatment is to:

Answer 21

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

Question 22

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

Answer 22

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