Delirium

Question 1

What perceptual problems can delirium cause?

Answer 1

Benign stimulus creating toxic perceptions eg visual hallucinations

Question 2

Woman with confusion after a knee replacement….

Answer 2

Delirium

Question 3

Presentation of delirium?

Answer 3

Impairment of consciousness, disturbance of cognition, psychomotor disturbance, disturbance of sleep-wake cycle, emotional disturbance

Question 4

Commonest presentation of delirium?

Answer 4

Patients seem distracted

Question 5

Describe the severity of impaired consciousness in medical terms from mild to severe

Answer 5

Clouding, drowsiness, sopor, coma

Question 6

What cognitive disturbances present in delirium?

Answer 6

Disorientation in time/place/person, impaired memory and attention, impaired thinking, visual hallucinations and illusions, delusions

Question 7

Describe the nocturnal worsening of symptoms in delirium

Answer 7

Fine in the morning/afternoon and then get “sundowning” at around 5-6pm

Question 8

Describe the sleep disturbances in delirium

Answer 8

Insomnia
Sleep loss
Reversal of sleep cycle
Nocturnal worsening - sundowning
Disturbing dreams and nightmares

Question 9

what patients are associated with NMDA receptor antibody encephalitis?

Answer 9

young women

associated teratoma

Question 10

fluctuating symptoms are usually indicative of a psychological/organic cause

Answer 10

organic

Question 11

Delirium comes on fast/slow

Answer 11

fast

Question 12

How long does delirium last?

Answer 12

1-4 weeks on average

Question 13

Delirium is a fluctuating disease T or F

Answer 13

T

Question 14

What perceptual disturbance is most common in organic brain disorders?

Answer 14

Visual hallucinations (NB auditory is more common in psychiatric disorders)

Question 15

Causes of delirium?

Answer 15

Infections, haemorrhage, MI, PE, heart failure, hypoxia, GI disorders, UTI, renal failure, intoxication eg analgesia/drugs, epilepsy, neuro disorders, trauma

Question 16

What drugs cause delirium?

Answer 16

Anticholinergics, anticonvulsants, antiparkinsonian drugs, steroids, cimetidine, opiates, sedatives

Question 17

Endocrine causes of delirium?

Answer 17

Hypoglycaemia
liver/kidney dysfunction
Deranged fluid/electrolyte balance
Hypo/hyperthyroidism
Hypopituitarism
Hypo/hyperparathyroidism

Question 18

Risk factors for delirium?

Answer 18

Age, existing dementia, previous episode, perioperative, extremes in temperature, existing deafness/blindness, immobility, social isolation

Question 19

Investigations in delirium?

Answer 19

MMSE/CAM/4AT, urinalysis (UTI), FBC, U+Es, LFTs, TFTs, glucose, CRP, B12 + folate (low levels of these can cause it), CXR (infection), MRI/CT brain (if trauma risk factors)

Question 20

Most important question to ask to differentiate delirium and dementia?

Answer 20

When did this start (acute = delirium, chronic = dementia)

Question 21

Tx of delirium?

Answer 21

Identify and treat cause, manage environment (correct sensory impairments eg hearing aids/glasses; bright sideroom), support, NB sedation may be necessary

Question 22

If a patient with delirium isn’t cooperating, they should be sedated before treatment T or F

Answer 22

T but only if they haven’t cooperated with other management first, sedatives can make delirium worse

Question 23

Sedating drugs to use in delirium?

Answer 23

Antipsychotics eg Haloperidol

Question 24

Dose of haloperidol required for an elderly person with delirium?

Answer 24

0.5mg only

Question 25

Why should patients with delirium be followed up quickly?

Answer 25

To rule out misdiagnosis of dementia

Question 26

What things on TV can help patients with delirium and why?

Answer 26

The news, it’s very repetitive and can help patients see what’s real

Question 27

Pharmacological Tx of delirium (include dose)?

Answer 27

Haloperidol 0.5mg-5mg orally then up to 10mg IM in 24hrs

Question 28

When would you not give haloperidol in delirium?

Answer 28

Alcohol withdrawal, Parkinson’s, Lewy Body Dementia, neuroleptic sensitivity

Question 29

When would you not give haloperidol in delirium?

Answer 29

Parkinson’s, LBD, neuroleptic sensitivity. alcohol withdrawal

Question 30

When would you give lorazepam for delirium? At what dose?

Answer 30

Parkinson’s, LBD, neuroleptic sensitivity; 0.5-2mg twice a day

Question 31

Describe hyperactive delirium?

Answer 31

Fine during the day, overactive at night; Agitation, disorientation, hallucinations and delusions, sometimes aggressive

Question 32

Describe hypoactive delirium?

Answer 32

Become suddenly quiet, withdrawn, sleepy, fluctuates throughout the day, doesn’t eat/drink/care, unmotivated/lazy/uncooperative, not engaging in rehabilitation, SUDDEN CHANGE!!!

Question 33

Most common misdiagnosis of hypoactive delirium?

Answer 33

Depression

Question 34

Describe mixed delirium?

Answer 34

Most common, vary through the day, “great at times awful at others”, asleep all day and awake all night, disruptive behaviour

Question 35

Most common psychiatric complication of stroke?

Answer 35

Post stroke depression (happens to 1/3 of patients)

Question 36

Depression is associated with MI T or F

Answer 36

T, very common and increases mortality!

Question 37

Features of K channel antibody associated encephalopathy?

Answer 37

Middle aged patient, with subacute memory loss, panic attacks, short-lived partial seizures

Question 38

Ix of KCAE?

Answer 38

MRI brain, mild hyponatraemia on U+Es, VGKC Abs are diagnostic

Question 39

Appearance of KCAE on imaging?

Answer 39

Hyperintensity medial temporal structures +/- cortical ribboning