Tutorial #35: Delirium

Question 1

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

Answer 1

1. Disturbance in attention and awareness
2. Onset is acute
3. Atleast one additional cognitive disturbance
4. Disturbances in A and C are not better explained by another neurocognitive disorder
5. There is evidence that disturbances above are a direct physiological consequence of another medical condition.

Question 2

What is the definition of sepsis?

Answer 2

Life-threatening organ dyfunction caused by a dysregulated host repsone to infection where organ dysfunction can be measured objectively using tools such as SOFA or qSOFA.

Question 3

What is the definition of septic shock?

Answer 3

Persistent hypotension despite adequate fluid resuscitation

+

initiation vasopressors to maintain MAP >= 65 mmHg

+

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

Question 4

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

Answer 4

1. antihistamines
2. tricyclic antidepressants
3. antipsychotics

Question 5

What are the symptoms of anticholinergic toxicity?

Answer 5

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)

Question 6

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

Answer 6

delirium - more abrupt decline in cognitive function

dementia - progressive, insidious decline over months to years.

Question 7

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

Answer 7

delirium - attention and orientation are impaired

dementia - attention and orientation are generally preserved

Question 8

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

Answer 8

Delirium - fluctuating, sometimes reduced

Dementia - Normal

Question 9

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

Answer 9

Delirium - incoherent, disorganized speech

Dementia - Variable

Question 10

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

Answer 10

Delirium - variable, with fluctuating impairments

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

Question 11

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

Answer 11

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

Question 12

What is the treatment for delirium?

Answer 12

Treat underlying cause, and then supportive measures.

Question 13

What are 6 causes of reversible dementia

Answer 13

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!