Patho EXAM review Flashcards
what is delirium
acute decline in the cognitive process of the brain (attention and cognition)
what age group does delirium generally affect?
65+
How does delirium influence cognitive function throughout the day?
cognitive function fluctuates through the day
What rate and why is delirium underreported?
2/3 cases are unreported because it is under-recognized due to variable signs and symptoms
what is the 1 year mortality rate?
35-40%
why is it important to address delirium?
delirium initiates a cascade of pathophysiological changes that can lead to loss of independence, increased morbidity and death.
what is the diagnostic criteria for delirium?
- disturbance in attention and awareness
- develops over a short period of time
- change from baseline attention and awareness and - fluctuates in severity during the day
- additional disturbance in cognition
- disturbances are not well explained by other/pre-existing neurocognitive disorders
- evidence from history/labs/physical exams show that the disturbance is a direct physiological consequence of another medical condition/intervention
what are the clinical features of delirium?
- acute onset
- fluctuating course
- inattention
- disorganized thinking
- altered LOC
- cognitive deficits
- perceptual disturbances (illusions)
- psychomotor disturbances
- altered sleep-wake cycles
- emotional disturbances
how does delirium differ form dementia, how are they the same
Similarities:
- both have impaired recent and remote memory
- orientation is impaired in delirium and may be impaired in dementia
Differences
- onset delirium is quick dementia is chronic
- course: delirium is short and worse at night and on awakening. Dementia is long, symptoms progress and stable over time
- progression: delirium is abrupt. Dementia is slow but even
- duration: delirium takes hours to less than one month. Dementia takes months to years
- awareness: delirium is reduced. Dementia is clear
- Attention: delirium is impaired and fluctuates. Dementia is generally normal
- thinking: delirium had disorganized, disoriented, incoherent and fragmented. Dementia there are impoverished thoughts, words are hard to find and poor judgment
- perception: delirium perception is disoriented, delusions & hallucinations, difficulty distinguishing between reality and misperceptions. Dementia, misperceptions are often absent
how does delirium differ from depression, how are they similar?
Similarities:
-diurnal effects (worse in the mornings)
Differences in
- onset
- course
- Progression
- duration
- awareness
- alertness
- attention
- orientation
- memory
- thinking
- perception
what are the types of delirium?
hyperactive, hypoactive and mixed
what are the characteristics if hyperactive delirium?
- restlessness, constant movement and agitation
- insomnia, hyper-vigilance, irritabilty, rpaid speech, distractibility
- may be mistaken for shizophrenia, bipolar or agitated dementia
what are the characteristics of Hypoactive delirium?
- most common in 65+
- slow or lacking movement, paucity (little to no) speech with or without prompting, unresponsiveness, decreased alertness
- may be mistaken for depression and is associated with higher mortality
what are the characteristics of mixed delirium
- more disruptive
- alternates between hypoactive and hyperactive
what causes delirium?
predisposing factors and precipitating factors
- 3 or more increase the risk of delirium by 60%
what is the pathophysiology of delirium?
The pathophysiology of delirium is poorly understood. The fluctuating course is the hallmark of delirium. there are multiped interacting risk factors. Most likely more than one neurobiological mechanism
what does the neuroinflammatory hypothesis of delirium entail?
- systemic inflammation is a predominant feature of many surgical and medical conditions associated with delirium
- delirium has clinical features of sepsis, UTIs, pneumonia, MIs, fractures etc
- delirious patients have higher blood plasma levels of inflammatory cytokines than pts. without delirium
- this creates an increased permeability of the BBB
- change occurs in all places that combat acute infections (ie. cytokine production, neuronal cell proliferation and HPA axis activations
- this explains how peripheral changes can affect brain function
- also explains why older individuals are more susceptible
what does the neurotransmitter hypothesis of delirium entail?
- acetylcholine is decreased and responsible for memory & cognition
- anticholinergic drugs cause delirium in healthy adults in the elderly population
- dopamine has an inhibitory effect on cholinergic activity. This means that dopamine agonists induce delirium and antagonists can treat delirium
- there are precipitating factors that can decrease acetylcholine synthesis in the brain
- high levels of serum anticholinergic activity are associated with increased risks of delirium
how can delirium be prevented
- modify risk factors
Interventions include: - orientation and therapeutic activity protocols, non-pharmacological sleep and sleep enhancement protocols, early mobilization protocol, vision protocol, hearing protocol, dehydration protocol
