Psychiatric Complications of Physical Disorders

Question 1

What is delirium?

Answer 1

AKA acute confusion

Impaired consciousness with intrusive abnormalities of perception and affect

Question 2

Occurrence of delirium?

Answer 2

Very common - most common mental health problem in hospitalised patients >65 years of age

Often missed, leading to an adverse impact on length of hospital stay, morbidity and mortality

Question 3

Main features of delirium?

Answer 3

1. Impaired consciousness - anywhere on the spectrum:
• Clouding
• Drowsiness
• Stupor
• Coma 

2. Disturbance in cognition:
   • Disorientation for time and, sometimes, place and person
   • Impaired memory and attention
   • Impaired thinking
   • Perceptual disturbances, hallucinations, delusions
3. Psychomotor disturbance - these are categories of delirium:
   • Hyperactive - patient is hyperalert
   • Hypoactive - patient is hypoalert
   • Mixed - most common
4. Sleep-wake cycle disturbance - patient can have insomnia, sleep loss, reversal of their sleep-wake cycle, nocturnal worsening of their symptoms, etc
5. Emotional disturbance - patients can have anxiety, fear, irritability, euphoria, apathy, etc; often, patients are mis-labelled with, e.g: depression

Question 4

Onset, course and resolve of delirium?

Answer 4

RAPID ONSET (patients develop the features suddenly; if their is a more gradual onset, consider dementia, depression, etc, although these patients may also acutely develop delirium)

Transient and fluctuating course

Lasts days-months, depending on the underlying cause

Question 5

Risk factors for delirium?

Answer 5

Age (elderly patients are more likely to develop delirium)

DEMENTIA (increases the likelihood)

Previous episode of delirium

Peri-operative period (usually following a long or emergency surgery)

Extremes of sensory experience, e.g: hypo/hyperthermia

Existing sensory deficit, e.g: blindness, deafness

Immobility

Social isolation

New environment

Stress

Question 6

Causes of delirium?

Answer 6

ANYTHING CAN CAUSE DELIRIUM, inc:
• Drugs, e.g: anti-cholinergics, anti-convulsants, Parkinsonian drugs
• Withdrawal, e.g: from alcohol, BZDs, barbiturates, illicit drugs
• Metabolic
• Infections
• Head trauma
• Epilepsy - can be ictal, pre-ictal, post-ictal, with ‘aura’
• Neoplastic disease
• Vascular disorders, e.g: TIA, thrombosis, embolism, migraine, MI, cardiac failure

NOTE - there may be NO IDENTIFIABLE CAUSE; this does not mean that the patient does not have delirium

Question 7

Ix in a patient suspected to have delirium?

Answer 7

Formal cognition tests (MMSE, CAM, ACE-R)

Urinalysis

FBC, U&Es, LFTs, TFTs, blood glucose, CRP, B12 & folate

CXR

MRI/CT brain

Consider an EEG (diffuse background slow-wave activity)

NOTE - be guided by any emerging underlying cause(s)

Question 8

Useful screening tool for delirium?

Answer 8

4AT

Question 9

Prevention of delirium?

Answer 9

Avoid medication and environmental changes; if any changes are going to be made, introduce them one at a time

Question 10

Management steps for delirium?

Answer 10

1. Identify and treat the cause of delirium - remember corroborative history, providing insight into patient’s recent activity and prescriptions, etc; sedation may be required initially, to proceed
2. Manage environment and provide support:
   • Educate staff (in recognising delirium and supporting patients)
   • Reality orientation (use clear communication, clocks and calendars)
   • Correct any sensory impairment, e.g: with hearing aids, glasses, etc
   • Use bright side-rooms, reduce noise, remove unsafe objects
   • Ensure basic needs are met, e.g: food, water, warmth
3. Prescribe
4. Review

Question 11

Pharmacotherapy used for delirium?

Answer 11

Anti-psychotics are the standard treatment for delirium

Haloperidol 0.5-5mg oral; proceed to IM if unsuccessful, up to 10mg in 24 hours

For Parkinson’s, Lewy body dementia, Neuroleptic sensitivity:
• Lorazepam (not diazepam) 0.5-2mg, up to 2 times in 24 hours

NOTE - use one drug at a time, start at a low dose and then increase

Question 12

Use of sedative drugs in patients with delirium?

Answer 12

Can worsen delirium by increasing confusion and unsteadiness

Question 13

Treatment of delirium in alcohol / sedative withdrawal?

Answer 13

Require regular prescribing of BDZs

Question 14

Prognosis of delirium?

Answer 14

Mean duration of 1-4 weeks, but this is usually longer in elderly patients

Some patient can have chronic delirium

Question 15

Consequences of delirium?

Answer 15

It is a risk factor for persisting cognitive impairment (dementia) and, potentially, for depression as well

Question 16

Features of hyperactive delirium?

Answer 16

Elderly patient +/- cognitive impairment; may have had a recent injury, e.g: hip fracture

Sudden-onset new confusion, agitation and restlessness

Patient may be fine during the day by hyperactive at night

Disruptive behaviour

Delusions

Question 17

Features of hypoactive delirium?

Answer 17

Same demographic as hyperactive, i.e: usually elderly patient +/- cognitive impairment

Suddenly become quiet, withdrawn

Fluctuates throughout the day

Patients may not eat, drink, care for themselves; the are often described as unmotivated, lazy, uncooperative and may be misdiagnosed as having depression

Do not engage in rehabilitation

Question 18

Features of mixed delirium?

Answer 18

Patients vary wildly within a 24 hour period and are often labelled as ‘behavioural’ (good at time and awful at others)

Asleep all day, awake all night with very disruptive behaviour

NOTE - mixed delirium is the most common type

Question 19

What is post-stroke depression?

Answer 19

The most common neuropsychiatric complication of stroke; 1/3rd of patients have major depression following a stroke

It affects cognition, motivation and rehabilitation

It is potentially treatable but unlikely to be preventable

Question 20

What is post-MI depression?

Answer 20

Following an MI, many patients develop depressive symptoms and some develop major depression

This increases mortality and is a risk factor for development of CV disease

Question 21

What is organic psychosis?

Answer 21

Psychosis caused by a physical disorder / abnormality; these patients tend to have VISUAL hallucinations