Delirium Flashcards
Delirium Pathophysiology:
Acetylcholine - The cholinergic system is involved in:
- Attention
- Arousal
- Memory
So, decreased cholinergic activity produces deficits in:
- ___ processing
- A___
- Attention and ability to ___
Dopamine
- An excess of dopamine may be a source of the ___, __ and __ in delirious patients
- There is an inverse relationship between __ and ___ levels
- _____ agents may induce delirium
Dopamine ____ are an effective treatment for delirium
GABA
- Increased in ____ encephalopathy
- Decreased in pts with __ ___
Others causes: histamine, serotonin, cytokines
Medications with anti-cholinergic effects can lead to delirium!
- OTC’s can also lead to delirium
Delirium Pathophysiology:
Acetylcholine - The cholinergic system is involved in:
- Attention
- Arousal
- Memory
So, decreased cholinergic activity produces deficits in:
- Information processing
- Attention
- Attention and ability to focus
Dopamine
- An excess of dopamine may be a source of the agitation, delusions and psychosis in delirious patients
- There is an inverse relationship between Ach and domapine levels
- Dopaminergic agents may induce delirium
Dopamine antagonists are an effective treatment for delirium
GABA
- Increased in hepatic encephalopathy
- Decreased in pts with alcohol withdrawal
Others causes: histamine, serotonin, cytokines
Medications with anti-cholinergic effects can lead to delirium!
- OTC’s can also lead to delirium
Diagnostic Work up of Delirium
____ - Obtain collateral info on baseline MSE
- Ascertain __ of ___ of sx
- Review ____, esp. recent med changes and potential drug interactions
Do an ___
Date: orientation
Place: orientation
Register three objects
Serial ___ (or spell ‘world backwards’)
Recall __ objects
Naming
Repeating
Verbal ___
Written ___
Writing Drawing - clock?
PE - Vital signs (+ anesthesia records, if pt is post-op)
- Pertinent physical findings of systemic disease (e.g. cyanosis, thyromegaly, rales, jugular venous distention, hepatomegaly, etc.
- Neurologic exam Lab Work Up
CBC
Chem-20
Serum drug levels
Arterial blood gas
Urinalysis and culture (UTI can cause delirium)
Urine drug screen
EKG
Chest X-ray
Syphilis (RPR)
Vitamin B12
HIV
Thyroid Function Tests
Lumbar Puncture
CT/MRI EEG
- *Diagnostic Work up of Delirium**
- *History** - Obtain collateral info on baseline MSE
- Ascertain time of onset of sx
- Review meds, esp. recent med changes and potential drug interactions
Do an MMS
Date: orientation
Place: orientation
Register three objects
Serial 7s (or spell ‘world backwards’)
Recall __ objects
Naming
Repeating
Verbal commands
Written commands
Writing Drawing - clock?
PE - Vital signs (+ anesthesia records, if pt is post-op)
- Pertinent physical findings of systemic disease (e.g. cyanosis, thyromegaly, rales, jugular venous distention, hepatomegaly, etc.
- Neurologic exam Lab Work Up
CBC
Chem-20
Serum drug levels
Arterial blood gas
Urinalysis and culture (UTI can cause delirium)
Urine drug screen
EKG
Chest X-ray
Syphilis (RPR)
Vitamin B12
HIV
Thyroid Function Tests
Lumbar Puncture
CT/MRI EEG
- *Is it reall delirium?**
- Many ___ and __ conditions can cause confusion and low scores on cognitive tests
- Delirium is a broad group of conditions having in common reduced level of __, __ and ___
- These deficits are presumed to be ___ if the cause is eliminated
- *Is it really delirium?**
- Many medical and psychological conditions can cause confusion and low scores on cognitive tests
- Delirium is a broad group of conditions having in common reduced level of consciousess, attention and concentration
- These deficits are presumed to be reversible if the cause is eliminated
___ of Delirium
- Causes distress in patients, family, & caregivers
- Increased risk for medical complications e.g., self-injury, pneumonia, decubitus ulcers, decreased self-management. - decreased recognition of medical conditions, self-care, compliance
- Elderly have ___x increased functional decline and risk of institutional placement over time
- Surgery patients have___ risk of complications, prolonged recovery, longer hosp stays, long-term disability. May have long-term impact on affect & cognition
- Excess mortality of 6.2 (hosp), 14.1 (during 1-5 yr f/u)
- Up to 20-75% of elderly delirious patients die during hospitalization and 25% within 6 months of onset
Outcomes of Delirium
- Causes distress in patients, family, & caregivers
- Increased risk for medical complications e.g., self-injury, pneumonia, decubitus ulcers, decreased self-management. - decreased recognition of medical conditions, self-care, compliance
- Elderly have 3x increased functional decline and risk of institutional placement over time
- Surgery patients have increased risk of complications, prolonged recovery, longer hosp stays, long-term disability. May have long-term impact on affect & cognition
- Excess mortality of 6.2 (hosp), 14.1 (during 1-5 yr f/u)
- Up to 20-75% of elderly delirious patients die during hospitalization and 25% within 6 months of onset
Psychosis is ____ fatal. Thus missing it, and not discovering the etiology, has the consequence of the patient ___ ___
. - Delirium is ____ fatal. - Thus missing it, and not discovering the etiology, comes with ___ consequences
Psychosis is never fatal. Thus missing it, and not discovering the etiology, has the consequence of the patient behaving badly
. - Delirium is often fatal. - Thus missing it, and not discovering the etiology, comes with serious consequences
Causes of Delirium: MI WATCH DEATH
Urgent Causes? WHHHHIMP
Causes of Delirium: MI WATCH DEATH
Medications - Opioids, sedative hypnotics, benzodiazepine, antibiotics
Infection – encephalitis, meningitis, syphilis, HIV, sepsis
Withdrawal – alcohol, barbiturates, sedative hypnotics
Acute metabolic – acidosis, alkalosis, electrolyte disturbance, hepatic failure,
Trauma - Closed head injury, heatstroke, burns
CNS pathology – Abscess, hemorrhage, hydrocephalus, seizures
Hypoxia - anemia, carbon monoxide, hypotension, cardiac failure
DEATH
Deficiencies – Vitamin B12, folate, thiamine
Endocrinopathies - Hyper/hypoglycemia, myxedema
Acute vascular - Hypertensive Encephalopathy, stroke
Toxins/drugs - Medications, illicit drugs, pesticides, solvents
Heavy Metals - Lead, manganese, mercury
Urgent Causes? WHHHHIMP
Wernicke’s encephalopathy / Withdrawal
Hypoxemia
Hypertensive encepholathy
Hypoglycemia
Hypoperfusion
Intracranial bleeding / infection
Meningitis / encephalitis
Poisons / medications
- Delirium is ___ ___ in cognitive functioning with fluctuations in attention span and other symptoms
- Delirium is a ___, though under-recognized condition
- ____ increases risk of delirium
- Management involves maximization of medical condition while minimization of ___
- Education is key
- Delirium is acute alteration in cognitive functioning with fluctuations in attention span and other symptoms
- Delirium is a serious, though under-recognized condition
- frailtyincreases risk of delirium
- Management involves maximization of medical condition while minimization of polypharmacy
- Education is key
Delirium - disturbances of consciousness with reduced ability to focus, sustain, or shift attention. It is a change in cognition or the development of a perceptual disturbance that is not better accounted for.
The disturbance develops over a ___ period of time and ___
Delirium - disturbances of consciousness with reduced ability to focus, sustain, or shift attention. It is a change in cognition or the development of a perceptual disturbance that is not better accounted for.
The disturbance develops over a short period of time and flucuates
How to differentiate between dementia and delirium?
- ____: pt can talk with you a little bit, but will be distracted (not able to sustain convo)
- ____: pt can have a conversation with you about 1974. They are attentive, but they have problems with memory
How to differentiate between dementia and delirium?
- Delirium: pt can talk with you a little bit, but will be distracted (not able to sustain convo)
- Dementia: pt can have a conversation with you about 1974. They are attentive, but they have problems with memory
___ - Strong memory component - gradual in onset
___ - Acute confusional state that brought on by another medical condition
- highly disorganized thinking
- fast
- inattention
- waxing and waning
- altered level of consciousness
Dementia - Strong memory component - gradual in onset
Delirium- Acute confusional state that brought on by another medical condition
- highly disorganized thinking
- fast
- inattention
- waxing and waning
- altered level of consciousness
Neurotransmitter imbalances involving acetylcholine, dopamine, and gamma aminobutyric acid (GABA) traversing cortical and subcortical nervous system pathways are seen in delirium. The chemical basis of delirium remains either a diffuse ____ of brain dopaminergic activity, a diffuse ___ in brain cholinergic activity, or both.
Most commonly, a relative excess of __ is implicated in the aetiology of the disorder and this may explain why __ blockers are helpful in providing symptomatic relief of delirium.
Neurotransmitter imbalances involving acetylcholine, dopamine, and gamma aminobutyric acid (GABA) traversing cortical and subcortical nervous system pathways are seen in delirium. The chemical basis of delirium remains either a diffuse excess of brain dopaminergic activity, a diffuse deficit in brain cholinergic activity, or both.
Most commonly, a relative excess of dopamine is implicated in the aetiology of the disorder and this may explain why dopamine blockers are helpful in providing symptomatic relief of delirium.
