"Physical (organic) disorders presenting with psychological and/or behavioural disturbance (e.g. delirium)" Flashcards
Name physical (organic) causes for a presenting complaint of:
Mood changes (depression/mania)
From Ox Handbook
MS
Stroke
DM
Brain tumour
Hypothyroidism
Name physical (organic) causes for a presenting complaint of:
Insomnia
From Ox Handbook
Sleep apnoea
Hyperthyroidism
GORD
Pain
Name physical (organic) causes for a presenting complaint of:
Insomnia
From Ox Handbook
Sleep apnoea
Hyperthyroidism
GORD
Pain
Name physical (organic) causes for a presenting complaint of:
Confusion/disorientation
From Ox Handbook
Renal failure
Cerebral arteritis
Sepsis
Name physical (organic) causes for a presenting complaint of:
Personality change
From Ox. Handbook
MS
Mass lesion
SLE
(i think FTDementia can do this too but not in book)
Name physical (organic) causes for a presenting complaint of:
Hallucinations
From Ox. Handbook
Migraine
Substance misuse
Encephalitis
Seizures
(LewyBodDem too i think - but not in book)
Name physical (organic) causes for a presenting complaint of:
Behavioural change
From Ox. Handbook
Vascular infarct
Lyme disease
Parkinson disease
Subdural haematoma
Mass lesion
Name physical (organic) causes for a presenting complaint of:
Psychosis
From Ox Handbook
Sensory loss
Syphilis
Dementia
Wilson’s disease
(substance misuse)
Name physical (organic) causes for a presenting complaint of:
Irritability
From Ox. Handbook
Vitamin B12 deficiency
Drug withdrawal (e.g. analgesics)
Substance misuse / withdrawal
Definition of delirium?
- Fluctuating impaired consciousness
- Onset is acute - over hours or days.
- Causes disturbed consciousness, attention, cognition, and perception
- There are 3 types - hyperactive, hypoactive and mixed delirium
What are predisposing factors for delirium?
NICE CKS
- Older age (over 65 years).
- Cognitive impairment (such as dementia).
- Frailty/multiple comorbidities (such as stroke or heart failure).
- Significant injuries such as hip fracture.
- Functional impairment (for example immobility or the use of physical restraints such as cot sides).
- Iatrogenic events (such as bladder catheterization, polypharmacy, or surgery).
- History of, or current, alcohol excess.
- Sensory impairment (such as visual impairment or hearing loss).
- Poor nutrition.
- Lack of stimulation.
- Terminal phase of illness.
What are precipitating factors of delirium?
NICE CKS
- Infection such as urinary tract infection, infected pressure sore, or pneumonia.
- Metabolic disturbance such as hypoglycaemia, hyperglycaemia (including advanced carcinomatosis), or electrolyte abnormalities (including dehydration).
- Cardiovascular disorders such as myocardial infarction or heart failure.
- Respiratory disorders such as pulmonary embolism or exacerbation of chronic obstructive pulmonary disease.
- Neurological disorders such as stroke, encephalitis, or subdural haematoma.
- Endocrine disorders such as thyroid dysfunction or Cushing’s syndrome.
- Urological disorders such as urinary retention.
- Gastrointestinal disorders such as hepatic failure, constipation (including faecal impaction), or malnutrition.
- Severe uncontrolled pain.
- Alcohol intoxication or withdrawal.
- Medications - (on another slide)
What medications can be precipitating factors for delirum?
- Opioids
- benzodiazepines (use and withdrawal),
- dihydropyridines (such as amlodipine)
- antihistamines (histamine-1 receptor antagonists)
Other drugs that have been associated with delirium include:
* dopamine agonists
* tricyclic antidepressants,
* lithium,
* antipsychotics,
* anticonvulsants,
* antiarrhythmics,
* antihypertensives,
* histamine-2 receptor antagonists,
* corticosteroids,
* NSAIDs
What psychosocial factors can precipitate delirium?
- depression,
- sleep deprivation,
- visual or hearing impairment,
- emotional stress,
- change of environment
Prevalence of delirium?
1-2% in the community, with 14% in over 85s
For inpatients - up to 50% in over 65s
What are clinical features of delirium?
Acute change in behaviour
Symptoms fluctuate - worst disturbance at night
Behavioural changes:
* altered cognitive function (disorientated, worsened conc, slow responses, confusion)
* Inattention ( easily distractible, unable to maintain focus)
* Disorganised thinking (rambling, illogical flow of ideas)
* Altered perception (paranoid delusions, misperceptions, hallucinations)
* Altered physical function - hyperactive, hypoactive, mixed.
* altered social behaviour - changes in mood and emotions. inappropriate behaviour
* altered level of consciousness - drowsy, disturbed sleep, complete sleep cycle reversal.
What are warning signs of delirium?
Falling
Loss of appetite
Differential diagnosis for delirium?
- withdrawal from drugs/alcohol
- mania
- depression
- post-ictal
- psychosis
- anxiety
- consider dementia - if insidious onset and have clear consciousness.
- thyroid disease
- Temporal lobe epilepsy or non-convulsive epilepsy
- Charles Bonnet syndrome
Causes of delirium
What are causes of delirium?
see image. Also see pg 733 of Ox Handbook.
What investigations would you do for a pt presenting with delirium?
Bloods: FBC, U+Es, ABG, Glucose, Blood cultures, LFTs
Bedside: MSU, ECG, LP
Imaging: CXR, CT
How would you manage delirium?
- Find precipitating cause and treat this.
- Optimise supportive surroundings and nursing care
- Avoid sedation unless they hve extreme agitation, risk or needed for investigations to take place. Give antipsychotics in 1st instance as benzos worsen delirium (apart from in alcohol withdrawal)
- Haloperidol 1-10mg/24hrs or Olanzapine 2.5-10mg/24hrs
- Regular review and follwo up.
What are the 4As of Alzheimers?
Amnesia
Agnosia
Aphasia
Apraxia
Define dementia?
Progressive and global intellectual deterioration without impairment of consciousness.
What is the prevalence of dementia?
6% in over 65s
(NICE says it is 7.1%)
What are reversible causes of dementia?
Subdural haematoma
Hydrocephalus
Hypothyroidism
For more cards on delirium and dementia, see OPIC decks
yay
