"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.
