Delirium and Disorders of Consciousness

Question 1

Delirium

Answer 1

Delirium is a reversible, acute-onset condition that typically develops over a short period of time and results in fluctuating and transient global cognitive dysfunction.

Question 2

Core diagnostic criteria of delirium

Answer 2

• Acute onset and fluctuation (hallmark feature): certain types of delirium are more prone to hyperactive or hypoactive states
• Disturbance of attention and awareness: often unable to maintain a coherent stream of thought or action and can be highly distractible and inattentive.
• Other cognitive impairments: e.g., memory impairment, visuospatial and or perceptual impairments (illusions)

Question 3

Pathophysiological causes of delirium

Answer 3

• neurotransmitter system dysfunction
• CNS response to inflammatory processes
• hypothalamic pituitary adrenal axis dysregulation
• direct cerebral insult/injury (e.g. diffuse brain injury, hypoxia)

Question 4

Neurotransmitters involved in delirium

Answer 4

Acetylcholine plays a role in attention, memory, and arousal - decrease in acetylcholine most likely contributes to impairments in attention and memory disturbance.

Excess dopamine or enhanced receptor site sensitivity is thought to be the cause of hallucinations.

Disruption or over excitation of serotonergic (serotonin) systems may cause hallucinations and emotional lability (e.g., hallucinogen intoxication).

Question 5

Predisposing Factors of delirium

Answer 5

Older age
dementia
severity of physical/chronic illness,
polypharmacy
metabolic disturbances
depression
sensory loss or dysfunction, respiratory failure or myocardial infarction
infections

Question 6

Precipitating Factors of delirium

Answer 6

Surgery
drug side effects
drug withdrawal
infections
iatrogenic complications

Question 7

Is delirium life threatening?

Answer 7

Yes.

If not identified or treated properly, patients can die or sustain permanent, debilitating medical or cognitive outcomes. Thus, all types of delirium are treated seriously, and patients typically require 24-hour monitoring such as that provided on the ICU or specialized hospital units.

Question 8

Assessment domains of delirium

Answer 8

Tools that assess basic, sustained, and divided attention should be stressed. Brief assessment at different times of day is recommended to track waxing and waning confusion.

Question 9

Environmental interventions for delirium

Answer 9

frequent orientation, cueing, and reassurance

use of large clocks and calendars

placing familiar objects in the room

quiet, well-lit surroundings

night lights

windows to help with time of day

having glasses and hearing aids available to improve sensory quality

avoidance of restraints and preference for one-on-one safety observers

presence of familiar faces and use of collateral support

Question 10

medication classes commonly associated with delirium:

Answer 10

tricyclic antidepressants, anticholinergics, benzodiazepines, corticosteroids, H2-receptor antagonists,
sedative hypnotics, anticonvulsants, antiparkinsonian drugs,
anti- inflammatories, and chemotherapy drugs.

Question 11

Serotonin syndrome

Answer 11

Typically caused by the conjoint use of multiple serotonergic agents. In the early stages, it can be marked by mental status changes, agitation, myoclonus, hyperreflexia, diaphoresis (sweating), tremor, diarrhea, incoordination, and fever. If left untreated and medications continue, death can occur.
tremor and diarrhea most common initially

Treatment requires the discontinuation of all serotonergic drugs and close monitoring with an expectation for improvement within 24 hours.

Question 12

Primary symptoms required for a diagnosis of delirium tremens (DTs)

Answer 12

confusion, autonomic hyperactivity, hallucinations

Question 13

Severe sepsis has been most commonly associated…

Answer 13

white matter compromise secondary to ischemic lesions

Question 14

Neuroleptic malignant syndrome (NMS)

Answer 14

A rare complication following neuroleptic use marked by muscle rigidity, pallor (pale skin), dyskinesia (involuntary motor movement), hyperthermia, incontinence, unstable blood pressure, tachycardia, and pulmonary congestion.

fever, increased blood pressure, and stiffness in his extremities

Treatment requires discontinuation of neuroleptics, intravenous hydration, and close monitoring of vital signs and mental status.

Question 15

Side effects of Levodopa can include:

Answer 15

delirium marked by hallucinations, confusion, and increased agitation

Parkinson medication

Question 16

Hallucinations in delirium vs. schizophrenia/psychosis

Answer 16

Delirium:
- hallucinations can be both formed (shapes, objects, people) and unformed (flashing lights, spots) in delirium

Psychosis:
- hallucinations are typically formed
- tend to be more auditory

Both:
- bizarre hallucinations can occur in both
- it is rare for them to vacillate between visual, tactile, and auditory in one individual.

Question 17

Delirium following discontinuation of long-term benzodiazepines is most similar to withdrawal from ???

Answer 17

Alcohol.

Benzodiazepines and alcohol target similar receptors.

Not surprisingly, discontinuation of long-term benzodiazepines results in withdrawal symptoms similar to withdrawal from alcohol. This is also why long-acting benzodiazepines are typically used to treat AWS.

Question 18

Locked in syndrome

Answer 18

occurs when there is focal injury to the brainstem (usually vascular lesion in the ventral pons due to basilar artery occlusion) and the patient cannot move but retains conscious awareness and volitional vertical gaze and eyelid movement.

Question 19

What medication carries the highest risk for the development of delirium following prolonged use at the prescribed dosage?

Answer 19

Corticosteroids. The term “steroid psychosis” has been used to describe conditions in which patients develop delirium and or mania often following prolonged use of corticosteroids to treat chronic illness.

Question 20

Two preexisting issues that are risk factors for postoperative delirium

Answer 20

executive dysfunction and depression

Question 21

high serum anticholinergic activity is associated with what?

Answer 21

Delirium