Psych - Delirium

Question 1

Delirium

Answer 1

ALWAYS DUE TO A MEDICAL PROBLEM - it is NOT an intrinsic psychiatric condition, but a consequence of underlying conditions or medications

It is a DISTURBANCE OF CONSCIOUSNESS and a change in cognition that develops over a short period of time

It is ALWAYS DUE TO A MEDICAL CONDITION OR SUBSTANCE

It is ALWAYS REVERSIBLE

Delirium = Encephalopathy

Question 2

DSM Criteria for Delirium

Answer 2

Disturbance in Consciousness –> reduced clarity of awareness of environment with a reduced ability to focus, sustain or shift attention
Low MMSE score b/c they lack the ability to maintain focus

A change in cognition – new onset memory deficit, disorientation, language disturbance. This type of deficit is different from Alzheimer’s because the onset is SUDDEN; also if any hallucinations are present, they are also very acute!

Develops over a short period of time and tends to fluctuate over the course of the day

The disturbance is caused by a GENERAL MEDICAL CONDITION OR A SUBSTANCE*

Question 3

Delirium vs. Dementia

Answer 3

DELIRIUM:

Course = ACUTE, REVERSIBLE
Consciousness = IMPAIRED
Attention = IMPAIRED
Memory = IMPAIRED (just can't focus on anything, not a loss of neurons or anything)
EEG = Diffuse Slowing

DEMENTIA:

Course = INSIDIOUS, IRREVERISBLE**
Consciousness = NORMAL**
Attention = NORMAL until late**
MEMORY = impaired
EEG = NORMAL but with diffuse slowing LATER

Question 4

Other possible symptoms of Delirium?

Answer 4

Transient delusional thoughts - when a patient all of a sudden thinks that nurses are coming to poison him when they are changing the IV; ANY PATIENT WITH NEW ONSET PSYCHOTIC BEHAVIORS IN A MEDICAL SETTING = DELIRIUM!

Sleep-wake cycle disturbance

Agitation (hyperactive) or decreased motor activity (hypoactive) –> Hyper = trying to pull out an IV, hypo = quiet, depressed looking

Emotional disturbances such as anxiety

Question 5

Neuropath of Delirium

Answer 5

There are three main areas of the brain that are thought to be involved –> the cerebral cortex, thalamus and basal ganglia

At the NT level, there are several things occurring, but two we care about:

REDUCED ACh activity
INCREASED DA activity

Question 6

Medical Causes of Delirium

Answer 6

Three systems are involved that leads to the alteration in NT activity

CNS –> delirium can be caused by HEAD TRAUMA, SEIZURES, POST-ICTAL STATE, HTN ENCEPHALOPATHY

Metabolic Disorders –> these can cause delirium via RENAL or LIVER failure, anemia, hypoxemia, hypoglycemia, thiamine deficiency (Wernicke’s encephalopathy - alcoholics), hyponatremia, hypercalcemia

Cardiopulmonary –> can cause delirium via CHF, arrhythmia, shock, respiratory failure

Question 7

Risk Factors for Delirium

Answer 7

Age
Systemic illness
Immunocompromised state
Postoperative
Systemic infection
Dementia
Dehydration

If normal and healthy, unlikely that delirium will be developed

Question 8

Substance-Induced Delirium

Answer 8

Can be caused by DRUGS OF ABUSE, like alcohol, amphetamines, cocaine or opioids

Delirium can be caused by regularly prescribed medications, like OPIOIDS (most common cause), anticholinergics (low ACh activity is a cause!!! Benadryl contraindicated for the elderly!!), anticonvulsants, corticosteroids, muscle relaxants, immunosuppressants, lithium

MEPERIDINE (OPIOID) is the MOST COMMON MEDICATION TO BE PRESCRIBED IN THE MEDICAL SETTING THAT WILL CAUSE DELIRIUM

Question 9

Substance-Withdrawal Delirium

Answer 9

Opposite of drug-induced is also true

Withdrawal delirium will ONLY OCCUR with the discontinuation of SEDATIVE HYPNOTICS – benzos, alcohol, barbiturates –> NO OTHER DRUGS!!!! Not opioids!

Delirium induced by alcohol = delirium tremens and is fatal!!

Question 10

MMSE for Delirium

Answer 10

Only have to focus on three parts for delirium

1) ORIENTATION – name, where they are, date, year, etc.
2) ATTENTION – have the patient count backwards; pick a VERY EASY THING TO DO - it will be more apparent if they are impaired. Count backwards from 10, for example.

One of the HALLMARKS of DELIRIUM is SUSTAINED ATTENTION DEFICITS (10, 9, 8, 7…7..7….7….7..6)

3) CLOCK DRAWING – draw a clock and put the hands at a specific time –> this involves multiple brain functions (attention, planning, visual-spatial orientation)

With delirium, it will be very SLOW, numbers on the clock will be weird and not spaced correctly, that SUSTAINED ATTENTION DEFICIT will be there as well - repeat some of the numbers (perseverance) and will have LONG PAUSES, forgetting what they are doing

Question 11

If a patient comes in with unexplained confusion….

Answer 11

BRAIN IMAGING MUST BE DONE!!!

Question 12

Treating Delirium

Answer 12

TREAT THE UNDERLYING CAUSE FIRST - it is ALWAYS caused by a medical condition or medication!!!!!

It is also very important to REASSURE THE PATIENT and the family that the patient is NOT PSYCHOTIC!!! This will alleviate a lot of anxiety

Then, ensure patient and staff safety!

Pharmacologic Treatment depends on the TYPE of delirium….

Question 13

Treating HYPERACTIVE agitated Delirium

Answer 13

ANTIPSYCHOTICS!!!!*

These will only treat the agitation, NOT the impaired cognition

***IV HALOPERIDOL is popular for agitated patients because it is easier than a pill or IM injection

Associated with ARRHYTHMIAS – Torsades!!!! Don’t give to patients with prolonged QT intervals!

If ANTIPSYCHOTICS DON’T WORK?

Lorazepam –> helps with agitation, but it could make the CONFUSION worse

Question 14

Treating SEDATIVE-HYPNOTIC WITHDRAWAL

Answer 14

Give BENZOS - LORAZEPAM!

Question 15

Treating HYPOACTIVE DELIRIUM

Answer 15

There is NO MEDICINAL TREATMENT; reassure the patient!