Delirium and eating disorders Flashcards
1
Q
Delirium
A
- A disturbance in attention (ex. reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment)
- The disturbance developes over a short period of time (hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day
- An additional disturbance in cognition (ex. memory deficit, disorientation, language, visuospatial ability, or perception).
- The disturbance in criteria A and C are not better explained by another preexisting, or evolving neurocognitive disorders and do not occur in cortext of severely reduced level of arousal, such as coma.
- There is evidence from the history, physical examinaion, or lab findings that the disturbance is a direct physiological consequence of another medical conditionl, substance intoxication or withdrawal or exposure to a toxin, or is due to multiple etiologies
2
Q
Delirium specifiers (cause)
A
- Substance intoxication delirium - this diagnosis is made instead of substane intoxication when the symptoms in criteria A and C predominate in the clinical picture and when they are sufficeicny severe to warrant clincial attention
- Substance withdrawal delirium
- Medication induced delirium
- Delirium due to another medical condition
- Delirium due to multiple etiologies
3
Q
Delirium specifiers
A
- Acute - lasting a few hours
- Persistent - lasting weeks or months. Tends to be associated with preceeding cogitive impairment
- Hyperactive - person has hyperactive level of psychomotor activity that mat be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care.
- Hypoactive - person has hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy and approaches stupor
- Mixed level of activity - individual has a normal level of psychomotor acitivty even though attention and wareness are disturbed. Also includes individuals whose levels rapidly fluctuates.
4
Q
Signs of delirium
A
- Questions need to be repeated because individuals attention wanders
- Individuals may perseverate with an answer to previous questions
- Individual is easily distracted by irrelevant stimuli
- Disturbance in awareness is manfiested by a reduced oritentation to the environment or at time even to onself
- Often associated with disturbance in sleep-wake cycle and may see complete reversal of nigh-day sleep-wake cycle
- Emotional disturbances - anxiety, fear, depression, irritability, anger, euphoria, and apathy.
5
Q
Causes of Delirium
A
- I - infectious - encephalitis, meningitis UTI, pnenmonia
- W - withdrawal (alcohol, barbiturates, benzos)
- A - acute metabolic disorder, electolyte imbalance
- T - Trauma - head injury, post-op
- C - CNS pathology - stroke, hemorrhage, tumour, seizure disorder, PD
- H - Hyoxia - anemia, cardiac failur, PE
- D - Deficiencies - vit B12, folic acid, thiamine
- E - Endocrinopathies - thryoid, glucose, parathryoid, adrenal
- A - Acute vascular - shock, vasculities, hypertenisve encephalopathy
- T - Toxins - substance use, sedatives, opioids, anticholingerics, anticonvulants, etc.
- H - Heavy metals - arsenic, lead, mercury
6
Q
Investigations Delirium
A
- Standard - CBC and differential, electrolytes (Ca, Mg, and P04), glucose, BUN, Cr, TSH/T4, LFTs, Vit B12, folate, albumin, urinalysis, urine C + S
- As indicated - ECG (to assess QT when considering treatment with antipsychotic), CXR, CT head, toxicology/heavy metal screen, veneral disease research laboratory, HIV, LP, blood cultures, EEG
7
Q
Confusion assessment method (CAM)
A
- Part 1 - an assessment instrument that screen for overall congitive impairment
- Part 2 - 4 features found best able to distinguish delirium from other cognitive impairments. Need 1+2 + (3 or 4)
- Acute onset and fluctuating course
- Inattention - patient has difficulty focusing attention, is easily distracted, or is having difficulty keeping track of what is being said
- Disorganized thinking
- Altered level of consciousness
8
Q
Treatment Delirium
A
- Treat underlying cause; stop all non-essential meds; maintain nutrition; hydration; electrolyte balance; and monitor vitals.
- Optimize environment - quiet setting, family present for reasurrance, orientation
- Pharmacotherapy
- low dose, high potency antipsychotics - haloperidol
- Benzos - onlt for alcohol withdrawal. Otherwise will worsen delirium.
9
Q
Pica
A
- Persistent eating of nonsubstance foods ≥1 month
- Earting of these “food” is inappropriate to developmental level
- Earting ot these “foods” is not culuturally or scoially normaitve
- If occuring in the context of another mental disorder, it is severe enough to warrent additional clincial attention
10
Q
Rumination Disoder
A
- Repeated regurgitatin of food ≥1 month. Regurgitation food may be re-chewed, re-swallowed, or spit out.
- Not attributable to GI or other medical cause
- Does not occur exclusively during course of anorexia nervosa, bulimia nervosa, binge-eating disoder, or avoidant/restrictive food intake disorder
- If occuring in context of another mental disorder of another neurodevelopmental disorders, they are sufficiently severe to warrant additional clinical attention
11
Q
Avoidant/Restrictive Food intake disoder
A
- Eating or feeing disturbance (ex. lack of interest in food/eating; avoidance based on sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet approriate nutritional and/or energy needs associated with one or more of the following
- Significant weight loss
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nuritional supplements
- Marked interference with psychosocial functioning
- Disturbance is not better explained by a lack of available food or by an assoicated culturally sanctioned practice
- Eating disturvance does not occur exclusively during course of AN or BN. No evidence of distrubance in way which one’s body weight or shape is experienced
- Disturbance is not attributable to concurrent medical condition or other mental disorder, or disturbace exceeds what is routinely associated with that disorder
12
Q
Anorexia Nervosa
A
- Restriction of energy intake relative to requriements, leading to a significantly low body weight
- Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even thought at a significantly low weight
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weightor shap on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight
- * Resticting type - in last 3 months, individual has not engaged in recurrent epiodes of binge eating or purging. Weight loss is accomplished primaryily thought deiting, fasting, and/or excessive exercise
- * Binge-eating/purging type - in last 3 months, individual has engaged in recurrent episodes of binge eating or purging behaviour
13
Q
Associated features Anorexia Nervosa
A
- Physiologcal disturbances - amenorrhea, vital sign abnormalities, reduced BMD
- Depressive signs and symptoms
- Obessive compulsive featues - both related and unrelated to food
- Often preoccupied with food - some collect recipes or hoard food
- Strong desire to control one’s environemtn, inflexible thinking, limited social spontaneity, restrained emotional expression
- Some may misuse medications in order to achieve weight loss
14
Q
Medical complications anorexia nervosa
A
- Cardiovascular
- decreased cardiac mass, reduced cardiac chamber volumes, mitral value prolapse, myocardiac fibrosis, pericardial effusion. Together, can result in reduced CO, reduced exercise capacity, attentuated blood pressure resposne to exercise, subjective fatigue.
- Bradycardiac, hypotension, QT dispersion, decreased diastolic ventricular function, and dimished heart rate variability
- Gynecologic
- Reduced secretion of gonadotropin releasing hormone, preventing ovulation and causing functional hypothalamic amenorrhea
- Endrocrine
- Adrenal - increase HPA activity in setting of chronic starvation leads to hypercartisolemia, which has been linked to depression, anxiety and osteopenia
- GH levels are high but downstream IGF-1 is low. Contributes to bone loss
- Thyroid - euthyroid sick pattern
- Antidiuretic hormone - can be low or high - associated with diabetes insipidus and SIADH, repecitively
- Bone - see profound bone loss and failure to accure normal bone mass
- GI
- Gastroparesis
- Constipation
- Renal and electrolytes
- May have reduced GFR and problems concentrating urine
- Hematologic
- cytopenias and bone marrow changes
- Neurologic
- Wernicks encephalophy
- Korsokoffs
- Brain atrophy
- Dermatologic
- Xerosis
- Lanugo
- Telogen effulvium
- Carotenoderma
15
Q
Bulimia nervosa
A
- Recurrent episodes of binge eating. An episode of binge eating is characterzed by both of the follwoing
- Eating, in a descrete period of time, an amount of food that is definitely larger than waht most individuals would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode
- Recurrent inappropriate compensatory beavours in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
- The binge eating and inappropriate compensatory behaviours both occurs, on average, at least once a week for 3 months
- Self-evalation is nderuly influenced by body shape and weight
- The disturbance does not occur exclusively during episodes of anorexia nervosa
