Delirium

Question 1

what is criterion A for delirium

Answer 1

a disturbance in ATTENTION (i.e reduced ability to direct, focus, sustain and shift attention) and AWARENESS (reduced orientation to environment)

Question 2

what is criterion B for delirium

Answer 2

the disturbance develops over a SHORT period of time (usually hours to days), represents a CHANGE from baseline attention and awareness and tends to FLUCTUATE in severity DURING THE COURSE OF A DAY

Question 3

what is criterion C for delirium

Answer 3

an additional disturbance in COGNITION (i.e memory deficit, disorientation, language, visuospatial ability or perception)

Question 4

what is criterion D for delirium

Answer 4

the disturbances in criteria A and C are not better explained by another preexisting, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma

Question 5

what is criterion E for delirium

Answer 5

there IS evidence from the history, physical exam or lab findings that the disturbance is a DIRECT, PHYSIOLOGICAL CONSEQUENCE of another medical condition, substance intoxication or withdrawal, or exposure to a toxin or is due to multiple etiologies

Question 6

list etiology specifiers for delirium

Answer 6

substance intoxication delirium substance withdrawal delirium medication induced delirium delirium due to another medical condition delirium due to multiple etiologies

Question 7

list timeline specifiers for delirium

Answer 7

acute–> lasting a few hours or days persistent–> lasting weeks or months

Question 8

list level of activity specifiers for delirium

Answer 8

hyperactive hypoactive mixed level of activity

Question 9

define hyperactive delirium

Answer 9

individual has hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care

Question 10

define hypoactive delirium

Answer 10

individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor

Question 11

define mixed level of activity delirium

Answer 11

normal level of psychomotor activity even though attention and awareness are disturbed also includes those whose activity level rapidly fluctuates

Question 12

when should you diagnose substance intoxication delirium instead of just substance intoxication

Answer 12

when symptoms in criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant medical attention *the same applies to substance withdrawal delirium

Question 13

how long does delirium usually last in hospital settings

Answer 13

about 1 week some symptoms often persist even after individuals are discharged from the hospital

Question 14

what is the essential feature of delirium

Answer 14

a disturbance of attention or awareness that is accompanied by a change in baseline cognition that cannot be better explained by a preexisting or evolving NCD

Question 15

how might a patients disturbance in attention present

Answer 15

reduced ability to direct, focus, sustain and shift attention i.e questions must be repeated because individuals attention wanders, or individual may perseverate with an answer to a previous question rather than appropriately shifting attention easily distracted by irrelevant stimuli

Question 16

how might disturbance in awareness present

Answer 16

reduced orientation to the environment or at times even to oneself

Question 17

what time of day does delirium often worsen and why

Answer 17

worsens in evening and nighttime when there is less external orienting stimuli

Question 18

which patients are more vulnerable to delirium

Answer 18

those with underlying NCD as the impaired brain function of those with major or mild MCD renders them more vulnerable to delirium

Question 19

which elements of cognition may be impaired in delirium (criterion C)

Answer 19

memory and learning (particularly RECENT MEMORY) disorientation (particularly to TIME and PLACE) alteration in language perceptual distortion or a perceptual-motor disturbance

Question 20

which perceptual disturbances can accompany delirium

Answer 20

misinterpretations illusions hallucinations *these disturbances are typically VISUAL but may occur in other modalities as well and range from simple and uniform to highly complex

Question 21

what is the continuum on which delirium finds itself

Answer 21

normal attention arousal–> delirium –> coma (coma is lack of any response to verbal stimuli–delirium cannot be diagnosed in the context of coma)

Question 22

how do you diagnose those patients who show only minimal responses to verbal stimuli

Answer 22

these patients are incapable of engaging with attempts at standardized testing or even interview this inability to engage should be classified as SEVERE INATTENTION low arousal states of acute onset should be recognized as indicating severe inattention and cognitive change and hence delirium

Question 23

how does delirium affect sleep

Answer 23

often associated with disturbance in the sleep-wake cycle can include: daytime sleepiness nighttime agitation difficulty falling asleep excessive sleepiness throughout the day wakefulness throughout the night can sometimes have COMPLETE REVERSAL of night-day sleep-wake cycle

Question 24

how important are sleep wake disturbances in delirium

Answer 24

very common have been proposed as a core criterion for the diagnosis

Question 25

how does delirium affect the patients emotional state

Answer 25

may exhibit emotional disturbances such as anxiety, fear, depression, irritability, anger, euphoria, apathy may be rapid and unpredictable shifts between emotional states may also be evident in calling out, screaming, cursing, muttering, moaning or making other sounds behaviours especially prevalent at night

Question 26

in which populations is the prevalence of delirium the highest

Answer 26

hospitalized older adults varies depending on individual characteristics, setting of care, sensitivity of detection method

Question 27

what is the prevalence of delirium in the community

Answer 27

1-2% (DSM 5) --\> increases with age

Question 28

what is the prevalence of delirium in the community in those above 85 years old

Answer 28

14% (DSM 5)

Question 29

what is the prevalence of delirium in older adults presenting to ERs

Answer 29

10-30% (DSM 5) in these cases, the delirium often represents a medical illness

Question 30

what is the prevalence of delirium in those admitted to hospital

Answer 30

14-24% (DSM 5) \*estimates of the incidence of delirium arising during hospitalization range from 6-56% in general hospitalized populations

Question 31

what is the incidence of post operative delirium in older populations

Answer 31

15-53% (DSM 5)

Question 32

what is the incidence of delirium in older individuals in ICU

Answer 32

70-80% (DSM 5)

Question 33

what is the incidence of delirium in nursing homes or post acute care settings

Answer 33

up to 60% (DSM 5)

Question 34

what is the incidence of delirium at end of life

Answer 34

up to 83% (DSM 5)

Question 35

what is the natural course of delirium

Answer 35

majority of people with delirium have a full recovery with or without treatment however, early recognition and intervention usually shortens duration of the delirium delirium can progress to stupor, coma, seizures or death, especially if underlying cause not addressed/treated

Question 36

what is the mortality among hospitalized individuals with delirium

Answer 36

high--\> as many as 40% of those with delirium, particularly those with malignancies and other sig medical illness, die within a year after diagnosis of delirium

Question 37

list environmental risk factors for delirium

Answer 37

functional impairment immobility hx of falls low levels of activity use of drugs and meds with psychoactive properties (esp alcohol and anticholinergics)

Question 38

list genetic and physiological risk factors for delirium

Answer 38

both major and minor NCDs can increase the risk for delirium and complicate the course older age higher susceptibility in infancy and childhood rather than in teens and adults

Question 39

describe EEG findings associated with delirium

Answer 39

generalized slowing fast activity is sometimes found (i.e in some cases of etoh withdrawal delirium) \*EEG is insufficiently sensitive and specific for diagnostic use

Question 40

why does delirium pose a risk to our patients

Answer 40

associated with an increased functional decline and risk of institutional placement hospitalized people over age 65 with delirium have three times the risk of nursing home placement and approx 3x the functional decline as hospitalized patients without delirium at both discharge and 3 months post discharge

Question 41

ddx for delirium

Answer 41

1. psychotic disorders and bipolar and depressive disorders with psychotic features 2. acute stress disorder 3. malingering and factitious disorder 4. other NCDs

Question 42

how to distinguish between delirium and an underlying NCD

Answer 42

acuteness of onset and temporal course

Question 43

what is attenuated delirium syndrome

Answer 43

applies in cases of delirium in which the severity of cognitive impairment falls short of that required for diagnosis or in which some, but not all, diagnostic criteria for delirium are met

Question 44

hyperactive delirium is more commonly associated with what etiologies

Answer 44

drug withdrawal and medication effects

Question 45

hypoactive delirium is more common in what population

Answer 45

elderly

Question 46

what % of people in nursing homes experience delirium

Answer 46

60%

Question 47

what % of peoplein the ICU experience delirium

Answer 47

70-87%

Question 48

what types of neurotransmitter dysfunctions can lead to delirum

Answer 48

cholinergic activation or inhibition dopamine activation serotonin activation or depletion cytokine excess cortisol excess glutamate activation GABA activation or reduced GABA activity

Question 49

what is the major anatomical area implicated in delirium

Answer 49

reticular formation in the brainstem this is the primary area of attention and arousal

Question 50

what is the major neurotransmitter hypothesized to be implicated in delirium

Answer 50

acetylcholine

Question 51

what factors might act through the following pathway to induce delirium: reduced GABA activity

Answer 51

benzo and alcohol withdrawal

Question 52

what factors might act through the following pathway to induce delirium: GABA activation

Answer 52

benzos hepatic failure

Question 53

what factors might act through the following pathway to induce delirium: glutamate activation

Answer 53

hepatic failure EtOH withdrawal

Question 54

what factors might act through the following pathway to induce delirium: cortisol excess

Answer 54

glucocorticoids cushings surgery stroke

Question 55

what factors might act through the following pathway to induce delirium: serotonin deficiency

Answer 55

surgical illness/medical illness-→ tryptophan depletion/phenylalanin elevation

Question 56

what factors might act through the following pathway to induce delirium: serotonin activation

Answer 56

medications substance withdrawal

Question 57

what factors might act through the following pathway to induce delirium: dopamine activation

Answer 57

medications stroke

Question 58

what factors might act through the following pathway to induce delirium: cholinergic activation

Answer 58

medications alcohol withdrawal

Question 59

what factors might act through the following pathway to induce delirium: cholinergic inhibition

Answer 59

medical illness/meds surgical illness

Question 60

list risk factors for delirium

Answer 60

over age 75 dementia chronic illness hx falls recent surgery recent med change dehydration pain sleep deprivation/environmental change alcohol/substance use

Question 61

at what time of day is delirium usually worse

Answer 61

evening

Question 62

how is sleep commonly affected in delirium

Answer 62

sleep wake cycle disturbance -→ daytime sleepiness, nighttime agitation/wakefulness may have complete day night reversal

Question 63

list the frontal release signs

Answer 63

palmar grasp palmomental reflex (scratch the palm) rooting reflex (stroke towards mouth) snout reflex (tap filtrum) glabellar reflex

Question 64

list indications for CT head in new delirium

Answer 64

focal neuro deficit anticoagulant use acute incontinence gait abnormality history of cancer

Question 65

what does EEG show in delirium

Answer 65

diffuse slowing of background activity (delta, theta waves)

Question 66

what does EEG show in delirium caused by EtOH or benzo withdrawal

Answer 66

delirium caused by EtOH or benzo withdrawal have low voltage fast activity

Question 67

what is the most effective nonpharm intervention to reduce days spent delirious

Answer 67

+++early mobilization

Question 68

what is the gold standard med for delirium management

Answer 68

haldol \*most evidence-→ for hypoactive too low anticholinergic risk (high EPS risk, QTc prolongation)

Question 69

what might you use as adjunct for refractory hyperactive delirium

Answer 69

VPA

Question 70

what medication reduces incidence of post op delirium

Answer 70

precedex/dexmetetomidine in IV infusion post op when compared to propofol or midaz

Question 71

how long does delirium usually last

Answer 71

about 1 week, can be longer in elderly may not return ot baseline if elderly

Question 72

what is the 3 month mortality rate for delirium

Answer 72

23-33% 1. year mortality may be as high as 50%

Question 73

what is the mortality rate of elderly patient who experience delirium in hospial

Answer 73

20-75% risk of mortality during that hospital stay after d/c 15% die within 1 month period

Question 74

what are some bedside tests for delirium

Answer 74

orientation attention (months backwards) digit span-→ forward is pure attention, backwards also tests working memory tapping A test luria memory delayed recall