Psychiatric Complications of Physical Disorders Flashcards
What is the most common mental health problem in hospitalized patients over 65?
Delirium
What is the mean prevalence of delirium?
20%
Diagnostic criteria for delirium?
Impairment of consciousness Disturbance of cognition Psychomotor disturbance Disturbance of sleep-wake cycle Emotional disturbance
What is included in impairment of consciousness seen in delirium?
Clouding
Drowsiness
Sopor
Coma (GCS)
What is included in disturbance of cognition in terms of delirium?
Disorientation for time but sometimes place and person too
Impaired memory and attention
Impaired thinking
Perceptual disturbance, visual hallucinations and illusions
What psychomotor variants are seen in delirium?
Hyperactive
Hypoactive
Mixed
Describe hyperactive delirium
Elderly (+/- cognitive impairment) Recent injury Sudden onset new confusion, agitation, restlessness Sundowning fluctuation Disruptive behaviour Delusions/ hallucinations of persecution
Describe hypoactive delirium
Suddenly quiet, withdrawn and sleepy Fluctuates throughout the day Doesn't eat, drink, tend to personal care Not engaging in rehab Often misdiagnosed as depression
What sleep disturbance is seen in delirium?
Insomnia Sleep loss Reversal of sleep cycle Nocturnal worsening of symptoms; sundowning Disturbing dreams and nightmares
What affective disturbances are seen in delirium?
Depression Anxiety Fear Irritability Euphoria Apathy Perplexity Aggression
What are the general features of delirium?
Rapid onset
Transient and fluctuating course
Lasts days to months depending on underlying cause
Causes of delirium?
Everything Cardiovascular disorders; intracranial/ subdural bleed, MI, PE, cardiac failure Resp: hypoxia GI; liver failure, pancreatitis Endocrine: diabetes, thyroid Infections GU; UTI, renal failure Intoxication: alcohol, drugs Neurological: head injury, meningitis, encephalitis, tumour, epilepsy Trauma; accidental or surgical
What drugs are commonly implicated in delirium?
Anticholinergic agents Anticonvulsants Anti-parkinson's drugs Steroids Cimetidine Opiates Sedatives Withdrawal from alcohol and illicit drugs
Metabolic causes of delirium
Hypoxia Hypoglycemia Compromised liver/ kidney function Deranged fluid/ electrolyte balance Hypo/ hyperthyroidism Hypopituitarism Hypo/ hyperparathyroidism Porphyria Carcinoid syndrome
Risk factors for development of delirium
Elderly Cognitive coexisting dementia Existing sensory deficits Previous episode Perioperative; long or emergency surgery Extremes in sensory experience; hypo/hyperthermia Immoblity Social isolation New environement Stress
Investigations in a new presentation of delirium?
History and full physical Formal cognitive test Urinalysis FBC, U&Es, LFTs Thyroid function BG CRP B12 and folate CXR MRI/ CT brain Consider EEG
What will be seen on EEG of someone suffering from delirium?
Diffuse background slow-wave activity
What cognitive assessment is used to diagnose delirium?
4AT; Alertness Orientation (4AMT; age, DOB, place, current year) Attention; years backwards Acute change or fluctuating course
Management of delirium
Identify and treat cause
Manage environment and provide support
Prescribe
Review
How should the environment be managed to help those with delirium?
Reality orientation; clear communication, clock, calendar
Correct sensory impairment; bring in glasses, hearing aids etc
Bright side room, reduce unnecessary noise
Ensure basic needs met; food, water, warmth
Should you instantly prescribe in delirium?
No; sedating drugs can worsen delirium by increased confusion and unsteadiness, consider practical management first
What is 1st line in treatment of agitation in delirium?
Haloperidol 0.5-5mg PO the IM up to 10mg in 24 hours
2nd line in treatment of delirium?
Lorazepam; 0.5-2mg up to 2x in 24 hours
How long does delirium tend to last?
1-4 weeks
Can be longer in elderly
How many post stroke patients have a major depression?
Up to 1/3rd
How many patients post MI have depressive symptoms?
65%
