Psychiatric Complications of Physical Disorders

Question 1

How common is delirium?

Answer 1

Most common mental health problem in hospitalised patients over 65%
Mean prevalence of 20%

Question 2

What effect does undertreatment of recognised delirium have?

Answer 2

Has adverse impact on length of stay, morbidity and mortality

Question 3

What are the central features of delirium?

Answer 3

Impaired consciousness = clouding, drowsiness, coma
Disturbance of cognition
Psychomotor disturbance = hyper/hypoalert
Disturbance of sleep-wake cycle
Emotional disturbance

Question 4

What are some examples of the cognitive disturbances seen in delirium?

Answer 4

Disorientation of time, impaired memory and thinking, visual hallucinations and illusions

Question 5

What are some examples of disturbance of the sleep-wake cycle in delirium?

Answer 5

Insomnia, sleep loss, reversal of sleep cycle, nocturnal worsening of symptoms, disturbing dreams

Question 6

What are some emotional disturbances that can occur in delirium?

Answer 6

Anxiety, fear, irritability, euphoria, apathy, perplexity, aggression

Question 7

What are some general features of delirium?

Answer 7

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

Question 8

What are some causes of delirium?

Answer 8

Intracranial/subdural bleed, MI, PE, heart failure, hypoxia
UTI, renal/liver failure, pancreatitis, thyroid disease
Alcohol, drugs, trauma, infection, tumours
Head injury, meningitis, encephalitis, epilepsy

Question 9

What are the risk factors for delirium?

Answer 9

Elderly, dementia, deafness/blindness, long or emergency surgery, hypo/hyperthermia, previous episode, immobility, social isolation, new environment, stress

Question 10

What investigations can be done for delirium?

Answer 10

History and full physical examination
FBC, U & Es, LTFs, thyroid function, blood glucose
Formal cognitive tests
CRP, B12, folate, CXR, CT or MRI of brain

Question 11

How is sedation used in delirium?

Answer 11

May be necessary to allow examinations

Sedating drugs can worsen delirium by increasing confusion and unsteadiness

Question 12

What are some basic things that can be done to help a patient with delirium?

Answer 12

Reality orientation = communication, clock, calendar
Correct sensory impairments and meet basic needs
Put in bright side room and reduce unnecessary noise

Question 13

What does alcohol withdrawl causing delirium need to resolve?

Answer 13

Reducing scale of benzodiazepines

Question 14

What is the standard treatment of delirium?

Answer 14

Haloperidol 1-10mg

Question 15

What is the follow up for patients with delirium?

Answer 15

Review patients regularly

Repeat cognitive assessment to avoid misdiagnosis of dementia

Question 16

What is the NHS Tayside protocol for treating delirium?

Answer 16

Haloperidol 0.5-5mg orally then IM, up to 10mg in 24hrs

For Parkinson’s, Lewy body dementia or neuroleptic sensitivity = lorazepam 0.5-2mg, up to 2x inn 24hrs

Question 17

What is the normal duration of delirium?

Answer 17

Mean duration is 1-4 weeks

Often longer in elderly

Question 18

What is the prognosis of delirium?

Answer 18

Minority become chronic

Risk factor for developing persistent cognitive impairment

Question 19

What are some features of post stroke depression?

Answer 19

Most common neuropsychiatric complication of stroke

Up to 1/3 stroke patients have major depression = affects cognition, motivation and rehabilitation

Question 20

What are some features of post MI depression?

Answer 20

65% have depressive symptoms = 15-22% of these have major depression
Increases mortality and is risk factor for developing CV disease