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 response to infection.
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!

Question 14

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

Answer 14

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

Question 15

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

Answer 15

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)

Question 16

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

Answer 16

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

Question 17

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

Answer 17

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

Question 18

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

Answer 18

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

Question 19

What does a DIMS delirium workup look like?

Answer 19

• 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

Question 20

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

Answer 20

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.

Question 21

What are positive/negative predictors for sepsis?

Answer 21

+ 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

Question 22

What are 3 broad steps to the management of sepsis?

Answer 22

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)