Delirium Flashcards

1
Q

what is criterion A for delirium

A

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

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2
Q

what is criterion B for delirium

A

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

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3
Q

what is criterion C for delirium

A

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

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4
Q

what is criterion D for delirium

A

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

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5
Q

what is criterion E for delirium

A

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

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6
Q

list etiology specifiers for delirium

A

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

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7
Q

list timeline specifiers for delirium

A

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

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8
Q

list level of activity specifiers for delirium

A

hyperactive hypoactive mixed level of activity

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9
Q

define hyperactive delirium

A

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

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10
Q

define hypoactive delirium

A

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

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11
Q

define mixed level of activity delirium

A

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

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12
Q

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

A

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

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13
Q

how long does delirium usually last in hospital settings

A

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

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14
Q

what is the essential feature of delirium

A

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

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15
Q

how might a patients disturbance in attention present

A

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

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16
Q

how might disturbance in awareness present

A

reduced orientation to the environment or at times even to oneself

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17
Q

what time of day does delirium often worsen and why

A

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

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18
Q

which patients are more vulnerable to delirium

A

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

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19
Q

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

A

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

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20
Q

which perceptual disturbances can accompany delirium

A

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

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21
Q

what is the continuum on which delirium finds itself

A

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

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22
Q

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

A

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

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23
Q

how does delirium affect sleep

A

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

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24
Q

how important are sleep wake disturbances in delirium

A

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

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25
Q

how does delirium affect the patients emotional state

A

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

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26
Q

in which populations is the prevalence of delirium the highest

A

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

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27
Q

what is the prevalence of delirium in the community

A

1-2% (DSM 5) –> increases with age

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28
Q

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

A

14% (DSM 5)

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29
Q

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

A

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

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30
Q

what is the prevalence of delirium in those admitted to hospital

A

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

31
Q

what is the incidence of post operative delirium in older populations

A

15-53% (DSM 5)

32
Q

what is the incidence of delirium in older individuals in ICU

A

70-80% (DSM 5)

33
Q

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

A

up to 60% (DSM 5)

34
Q

what is the incidence of delirium at end of life

A

up to 83% (DSM 5)

35
Q

what is the natural course of delirium

A

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

36
Q

what is the mortality among hospitalized individuals with delirium

A

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

37
Q

list environmental risk factors for delirium

A

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

38
Q

list genetic and physiological risk factors for delirium

A

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

39
Q

describe EEG findings associated with delirium

A

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

40
Q

why does delirium pose a risk to our patients

A

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

41
Q

ddx for delirium

A
  1. psychotic disorders and bipolar and depressive disorders with psychotic features 2. acute stress disorder 3. malingering and factitious disorder 4. other NCDs
42
Q

how to distinguish between delirium and an underlying NCD

A

acuteness of onset and temporal course

43
Q

what is attenuated delirium syndrome

A

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

44
Q

hyperactive delirium is more commonly associated with what etiologies

A

drug withdrawal and medication effects

45
Q

hypoactive delirium is more common in what population

A

elderly

46
Q

what % of people in nursing homes experience delirium

A

60%

47
Q

what % of peoplein the ICU experience delirium

A

70-87%

48
Q

what types of neurotransmitter dysfunctions can lead to delirum

A

cholinergic activation or inhibition

dopamine activation

serotonin activation or depletion

cytokine excess

cortisol excess

glutamate activation

GABA activation or reduced GABA activity

49
Q

what is the major anatomical area implicated in delirium

A

reticular formation in the brainstem

this is the primary area of attention and arousal

50
Q

what is the major neurotransmitter hypothesized to be implicated in delirium

A

acetylcholine

51
Q

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

reduced GABA activity

A

benzo and alcohol withdrawal

52
Q

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

GABA activation

A

benzos

hepatic failure

53
Q

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

glutamate activation

A

hepatic failure

EtOH withdrawal

54
Q

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

cortisol excess

A

glucocorticoids

cushings

surgery

stroke

55
Q

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

serotonin deficiency

A

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

56
Q

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

serotonin activation

A

medications

substance withdrawal

57
Q

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

dopamine activation

A

medications

stroke

58
Q

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

cholinergic activation

A

medications

alcohol withdrawal

59
Q

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

cholinergic inhibition

A

medical illness/meds

surgical illness

60
Q

list risk factors for delirium

A

over age 75

dementia

chronic illness

hx falls

recent surgery

recent med change

dehydration

pain

sleep deprivation/environmental change

alcohol/substance use

61
Q

at what time of day is delirium usually worse

A

evening

62
Q

how is sleep commonly affected in delirium

A

sleep wake cycle disturbance -→ daytime sleepiness, nighttime agitation/wakefulness

may have complete day night reversal

63
Q

list the frontal release signs

A

palmar grasp

palmomental reflex (scratch the palm)

rooting reflex (stroke towards mouth)

snout reflex (tap filtrum)

glabellar reflex

64
Q

list indications for CT head in new delirium

A

focal neuro deficit

anticoagulant use

acute incontinence

gait abnormality

history of cancer

65
Q

what does EEG show in delirium

A

diffuse slowing of background activity (delta, theta waves)

66
Q

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

A

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

67
Q

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

A

+++early mobilization

68
Q

what is the gold standard med for delirium management

A

haldol

*most evidence-→ for hypoactive too

low anticholinergic risk (high EPS risk, QTc prolongation)

69
Q

what might you use as adjunct for refractory hyperactive delirium

A

VPA

70
Q

what medication reduces incidence of post op delirium

A

precedex/dexmetetomidine

in IV infusion post op

when compared to propofol or midaz

71
Q

how long does delirium usually last

A

about 1 week, can be longer in elderly

may not return ot baseline if elderly

72
Q

what is the 3 month mortality rate for delirium

A

23-33%

  1. year mortality may be as high as 50%
73
Q

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

A

20-75% risk of mortality during that hospital stay

after d/c 15% die within 1 month period

74
Q

what are some bedside tests for delirium

A

orientation

attention (months backwards)

digit span-→ forward is pure attention, backwards also tests working memory

tapping A test

luria

memory delayed recall