Psychiatric Complications of Physical Disorders

Question 1

What happens in delirium?

Answer 1

Patients have impaired consciousness which causes abnormal and intrusive perceptions

=> patients misperceive benign visual stimuli as unpleasant

Question 2

What features are required for a diagnosis of delirium?

Answer 2

• Impairment of consciousness (drowsy -> coma)
• Disturbance of Cognition
• Psychomotor Disturbance
• Disturbance of sleep-wake cycle
• Emotional disturbance

Question 3

What cognitive disturbances are usually present in delirium?

Answer 3

Disorientation in time, place and person
Memory/attention deficits
Impaired perception (hallucinations/illusions/delusions)

Question 4

What is meant by the psycho-motor disturbances seen in delirium?

Answer 4

Hyperactive - agitated, aggressive, hallucinating
Hypoactive - (often missed) withdrawn, sleepy
Mixed

Question 5

How is a person’s sleep-wake cycle disturbed during delirium?

Answer 5

insomnia
reversal of cycle => awake at night, asleep during day
Nocturnal worsening of symptoms
Nightmares

Question 6

How do patients with delirium become emotionally disturbed?

Answer 6

• Depression/anxiety
• fear
• apathy/withdrawn
• irritated/aggressive

Question 7

Describe the typical onset and course of a delirium?

Answer 7

Rapid onset
Transient and fluctuating course
Lasts days to months depending on underlying cause

Question 8

In what groups of patients is delirium most prevalent?

Answer 8

Elderly inpatients
Oncology
AIDS
Terminally ill

Question 9

What can cause a delirium?

Answer 9

Literally ANYTHING
e.g. 
infection
hypoxia
serious bleeds
etc

Question 10

Why does it take a very serious insult to give younger patients delirium?

Answer 10

Reserve capacity of brain is high

=> only usually caused by large trauma, high dose of analgesia etc

Question 11

Drugs can cause delirium even after they are stopped. TRUE/FALSE?

Answer 11

TRUE
if patient experiences withdrawal this can make them delirious
=> Sedatives (benzodiazepines)
=> Barbiturates
=> Alcohol and Illicit drugs

Question 12

What types of drugs are known to cause a delirium?

Answer 12

Anticholinergics
Anticonvulsants
Anti-parkinsons drugs
Steroids
Opiates
Sedatives
ALCOHOL
ILLICIT DRUGS

Question 13

If you cannot identify a cause for delirium then this should be excluded as a diagnosis. TRUE/FALSE?

Answer 13

FALSE

sometimes a cause will never be found but patient will still be considered delirious

Question 14

What are the main risk factors for the development of delirium?

Answer 14

age
dementia
previous episode of delirium
surgery
existing sensory deficits (sight/hearing problems)

Question 15

What are the main investigations used in delirium?

Answer 15

FORMAL Cognitive tests (MMSE, 4AT, ACE-R, MoCA)

Question 16

What other investigations would you do in patients with delirium to rule out reversible causes?

Answer 16

FBC, U&Es
Thyroid Function Tests
B12 and folate

Question 17

How is treatment of delirium usually approached?

Answer 17

Identify and treat the cause (if possible)
Manage environment and provide support
Prescribe
Review

Question 18

What is included in the 4AT tool for delirium?

Answer 18

Alertness
Orientation
Attention
Acute change/fluctuating

Question 19

If a patient with delirium is requiring to beb sedate dto comply with examination/investigations, what sedative should be used?

Answer 19

Short acting e.g. lorazepam

as opposed to diazepam etc

Question 20

How should we modify a delirious patients environment to make them more comfortable?

Answer 20

• Quiet and well lit side room (if possible)
• Remove unnecessary equipment
• Educate staff to reassure patients (often scared/frightened by their delirium)
• Use items to orientate the patient (TV on, newspapers, clock, reminders from home etc)
• Correct sensory impairment by making sure they have glasses/ hearing aids etc

Question 21

What treatments can be prescribed for delirium?

Answer 21

Sedating drugs can worsen delirium by increasing confusion and unsteadiness
=> Antipsychotics are standard treatment e.g. Haloperidol

Question 22

Why is it important to review patients with delirium?

Answer 22

• patients can improve quickly
  => no longer need prescribed meds!
• patients can worsen quickly and suffer seizures/injuries/sudden death
• Follow Up – repeat cognitive assessment to avoid misdiagnosis of dementia

Question 23

What patients should NOT be given haloperidol when treating delirium?

Answer 23

Parkinson’s
Lewy Body Dementia
Neuroleptic Sensitivity

Question 24

What is the average duration of a delirium?

Answer 24

• Mean duration of Delirium is 1-4 Weeks
• Often longer in the elderly
• A minority can become chronic

Question 25

What is the most common neuropsychiatric complication of stroke?

Answer 25

Post stroke depression

Question 26

How many patients have a Major Post stroke depressive episode?

Answer 26

Up to 1/3 of stroke patients

Question 27

How many patients experience depression following an MI?

Answer 27

65% patients = depressive symptoms

15-22% of these = major depression