Tutorial #35: Delirium Flashcards
What are the 5 criteria in the DSM-5 that need to be met for a diagnosis of delirium?
- Disturbance in attention and awareness
- Onset is acute
- Atleast one additional cognitive disturbance
- Disturbances in A and C are not better explained by another neurocognitive disorder
- There is evidence that disturbances above are a direct physiological consequence of another medical condition.
What is the definition of sepsis?
Life-threatening organ dyfunction caused by a dysregulated host response to infection.
Organ dysfunction can be measured objectively using tools such as SOFA or qSOFA.
What is the definition of septic shock?
Persistent hypotension despite adequate fluid resuscitation
+
initiation vasopressors to maintain MAP >= 65 mmHg
+
Lactate >= 2 mmol/L in the absence of hypovolemia
Which medications have a significant anticholinergic side effect? (x3)
- antihistamines
- tricyclic antidepressants
- antipsychotics
What are the symptoms of anticholinergic toxicity?
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)
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In terms of onset of symptoms how can you differentiate between delirium vs dementia?
delirium - more abrupt decline in cognitive function
dementia - progressive, insidious decline over months to years.
In terms of attention how can you differentiate between delirium vs dementia?
delirium - attention and orientation are impaired
dementia - attention and orientation are generally preserved
In terms of level of consciousness how can you differentiate between delirium vs dementia?
Delirium - fluctuating, sometimes reduced
Dementia - Normal
In terms of speech and langauge how can you differentiate between delirium vs dementia?
Delirium - incoherent, disorganized speech
Dementia - Variable
In terms of memory for recent and past events how can you differentiate between delirium vs dementia?
Delirium - variable, with fluctuating impairments
Dementia - often impaired for recent events (in later stages, long term memory becomes impaired)
What is the Confusion Assessment Method (CAM) for delirium?
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
What is the treatment for delirium?
Treat underlying cause, and then supportive measures.
What are 6 causes of reversible dementia
- CNS infections
- hypothyroidism
- Vitamin B12 deficiency
- CNS masses (neoplasms, subdural hematomas)
- Normal-pressure hydrocephalus
- 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!
What are DIMS causes for delirium (i.e. name the categories)
Drugs
Infection/inflammation
Metabolic (largest category)
Structural (“brain” problem)
What are the “D” causes of delirium in DIMS?
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)
What are the “I” causes of delirium in DIMS?
Infection/inflammation: Sepsis, CNS infections (meningitis/encephalitis), vasculitis, syphilis, rheumatological (i.e. lupus cerebritis), post-operative
What are the “M” causes of delirium in DIMS?
Metabolic (largest category): electrolyte disturbances, organ failure (cardiac, hepatic, renal), endocrinopathies (thyroid, glucose), vitamin deficiencies (B12, thiamine)
What are the “S” causes of delirium in DIMS?
Structural (“brain” problem): trauma, stroke, ICH, hydrocephalus, seizures, tumors, hypertensive encephalopathy
What does a DIMS delirium workup look like?
- 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
What is a Choosing Wisely statement for the workup of delirium in hospitalized patients?
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.
What are positive/negative predictors for sepsis?
+ Predictors ↑WBC, confusion, tachycardia, fever, source of infection found on history or exam.
- Predictors No confusion, no organ dysfunction, afebrile, normal WBC, normal vital signs
What are 3 broad steps to the management of sepsis?
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)
