Tutorial #35: Delirium Flashcards

(45 cards)

1
Q

What are the 5 criteria in the DSM-5 that need to be met for a diagnosis of delirium?

A

a) Disturbance in attention and awareness
b) Onset is acute
c) At least one additional cognitive disturbance
d) Disturbances in A and C are not better explained by another neurocognitive disorder
e) There is evidence that disturbances above are a direct physiological consequence of another medical condition.

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2
Q

What is the definition of sepsis?

A

Life-threatening organ dyfunction caused by a dysregulated host response to infection.

(ngl this is high yield, I have been pimped on this multiple times in 2nd year)

Organ dysfunction can be measured using tools such as SOFA/qSOFA.

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3
Q

What is the definition of septic shock (x3)?

A

Persistent hypotension despite adequate fluid resuscitation

+

initiation vasopressors to maintain MAP >= 65 mmHg

+

Lactate >= 2 mmol/L in the absence of hypovolemia

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4
Q

Which medications have a significant anticholinergic side effect? (x3)

A
  1. antihistamines
  2. tricyclic antidepressants
  3. antipsychotics

There are a lot of meds w/ antichol effects, these are just three common ones

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5
Q

What are the symptoms of anticholinergic toxicity (x6)?

A

Red as a beet (flushing)
Dry as a bone (anhidrosis)
Hot as a hare (hyperthermia)
Blind as a bat (blurry vision)
Mad as a hatter (agitated delirium)
Full as a flask (urinary retention)

ngl I just rmbr it as increased SNS, EXCEPT that skin is dry

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6
Q

In terms of onset of symptoms how can you differentiate between delirium vs dementia?

A

delirium - more abrupt decline in cognitive function

dementia - progressive, insidious decline over months to years.

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7
Q

In terms of attention how can you differentiate between delirium vs dementia?

A

delirium - attention and orientation are impaired

dementia - attention and orientation are generally preserved

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8
Q

In terms of level of consciousness how can you differentiate between delirium vs dementia?

A

Delirium - fluctuating, sometimes reduced

Dementia - Normal

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9
Q

In terms of speech and langauge how can you differentiate between delirium vs dementia?

A

Delirium - incoherent, disorganized speech

Dementia - Variable

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10
Q

In terms of memory for recent and past events how can you differentiate between delirium vs dementia?

A

Delirium - variable, with fluctuating impairments

Dementia - often impaired for recent events (in later stages, long term memory becomes impaired)

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11
Q

What is the Confusion Assessment Method (CAM) for delirium?

A

A patient is most likely delirious if:

The patient has both:
a. The mental status change is of acute onset and fluctuating course AND
b. There is inattention

and at least 1 of:

c. presence of disorganized thinking OR
d. There is an altered level of consciousness

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12
Q

What is the treatment for delirium (x2)?

A

Treat underlying cause, and then supportive measures.

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13
Q

What are 6 causes of reversible dementia

A
  1. CNS infections
  2. hypothyroidism
  3. Vitamin B12 deficiency
  4. CNS masses (neoplasms, subdural hematomas)
  5. Normal-pressure hydrocephalus
  6. Medications

The testing threshold for these etiologies of dementia is very low. Consider ruling these out in your workup of a patient who is presenting with cognitive decline!

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14
Q

What are DIMS causes for delirium (i.e. name the categories)

A

Drugs
Infection/inflammation
Metabolic (largest category)
Structural (“brain” problem)

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15
Q

What are the “D” causes of delirium in DIMS?

A

Drugs (therapeutic, intoxication or withdrawal): Prescription medications, illicit drugs, pesticides, solvents, environmental/heavy metal exposure, post-anesthesia, alcohol (intox or withdrawal), sedative hypnotic (intox or withdrawal)

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16
Q

What are the “I” causes of delirium in DIMS?

A

Infection/inflammation: Sepsis, CNS infections (meningitis/encephalitis), vasculitis, syphilis, rheumatological (i.e. lupus cerebritis), post-operative

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17
Q

What are the “M” causes of delirium in DIMS?

A

Metabolic (largest category): electrolyte disturbances, organ failure (cardiac, hepatic, renal), endocrinopathies (thyroid, glucose), vitamin deficiencies (B12, thiamine)

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18
Q

What are the “S” causes of delirium in DIMS?

A

Structural (“brain” problem): trauma, stroke, ICH, hydrocephalus, seizures, tumors, hypertensive encephalopathy

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19
Q

What does a DIMS delirium workup look like?

A
  • Drugs: can be identified history, toxidrome or patient’s medication list
  • Infection: icareful head-to-toe exam, identify source (urine, imaging), gather cultures and start empiric antibiotics
  • Metabolic: order appropriate lab studies including TSH where appropriate
  • Structural: consider CT brain
20
Q

What is a Choosing Wisely statement for the workup of delirium in hospitalized patients?

A

Don’t routinely obtain head computed tomography (CT) scans, in hospitalized patients with delirium in the absence of risk factors.

Delirium is a common problem among hospitalized patients. In the absence of risk factors for intracranial causes of delirium (such as recent head trauma or fall, new focal neurological findings, and sudden or unexplained prolonged decreased level of consciousness), routine head CT scans are of low diagnostic yield. Guidelines suggest a step-wise approach to the management of new delirium in hospitalized patients and consideration of head CT only in patients with select risk factors.

21
Q

What are positive/negative predictors for sepsis?

A

+ve Predictors
↑WBC, confusion, tachycardia, fever, source of infection found on history or exam.

-ve Predictors
No confusion, no organ dysfunction, afebrile, normal WBC, normal vital signs

22
Q

What are 3 broad steps to the management of sepsis?

A

The treatment of sepsis can be complicated, but the basics include:
* Resuscitation including fluids, vasopressors and airway management as needed
* Early initiation of appropriate broad-spectrum antibiotics
* Adequate source control (the diagnostic workup is to address this last point)

in short, resus + abx + source ctrl

23
Q

What are two CNS causes of reversible dementia?

A

CNS infection
CNS mass

24
Q

What is a common endocrine cause of reversible dementia?

A

Hypothyroidism

25
What is a common vitamin deficiency that can cause reversible dementia?
B12 deficiency
26
In the reading, CNS infections, CNS masses, B12 deficiency, and hypothyroidism are listed as causes of reversible dementia. What are the two other causes listed?
NPH Meds
27
Is memory loss reported by a patient's family more indicative of dementia or depression?
Dementia | Self-reported can still be dementia, but also should consider MDD
28
If you have a patient with delirium, and suspect a drug cause, what is next step?
Identify via hx, toxidrome, or pt med list
29
If you have a patient with delirium, and suspect a infection cause, what is next step (x3)?
Identify source, cultures, abx
30
If you have a patient with delirium and suspect a metabolic cause, what is next step?
Order appropriate labs (i.e. TSH, etc.)
31
If you have a patient with delirium and suspect a strutural cause, what is the next step?
CT brain
32
What are the SIRS criteria that used to be used for sepsis?
2/4 of temp > 38 or < 36 HR > 90 RR > 20 WBC > 12 or < 4 (ngl idk how much this will show up in CR2 since it's old criteria, but I have been pimped on this multiple times by docs in general)
33
What is the rule out test for sepsis?
NONE (trick Q) | per reading 50% of sepsis pt will have -ve culture
34
What do the vitals of a patient with sepsis look like (i.e. BP, temp, RR, and HR)?
HoTN Fever Tachypnea Tachycardia (decreased BP triggers increase in HR to comprensate if we think about it physiologically)
35
Patients with anticholinergic toxidrome present with sweaty skin, true or false?
False (dry as a bone) | Most important one to know since it diff from SNS agents
36
What is expected on EKG in a patient with anticholinergic toxidrome?
prolonged QT | which is why we order ekg in these patients (helps w/ dx and mgmt)
37
In a patient with anticholinergic toxidrome, if you suspect rhabdo, what two tests should be ordered (assume you have already ordered lytes)?
CK Renal tests (i.e. Cr, BUN, etc.)
38
Is delirium an end diagnosis?
NO (always 2/2 something else)
39
What is the most common cause of dementia?
AD | 67% of cases per reading
40
Memory loss, personality change, and language impairments (i.e. aphasia, word substitutions, etc.) that interfere with the ability to perform ADLs in a patient over the age of 65 is indicative of what cause of dementia?
AD
41
What is the confirmatory test for AD?
Autopsy | Dx of exclusion otherwise
42
What is the rule out test for AD?
Normal MMSE (w/ no other pathology)
43
What is the pharmacotherapy for AD (x3)?
1) Cholinesterase inhibitors (AD patients have low Ach, so use drugs to increase ach) 2) Memantine 3) Neuropsych meds s/a antipsychotics
44
What is the non-pharm treatment/mgmt of AD (x5)?
1) Couselling/Education 2) Safety measures 3) Behavior changes (and preparation for them) 4) Depression treatment (50% cases are comorbid) 5) Caregiver support (support groups, etc.)
45
What are the 5 steps of calling a consult?
1) Greeting 2) Who you are/what service 3) Reason for consult 4) Describe case 5) Ask if anything else they would like done, say thank you