Delirium

=Reading= 4pp, andreason =Goals=

7. Identify delirum if given a case report, highlighting those features that suggest delirium, listing potential causses, and suggesting an initial work-up
Delirium Believe that this hour may be most important very common problem form of brain failure pt very sick take care....may die or be damaged don't think is a psych illness psychiatric symptoms of physiological illness in body features transient, reversible cerebral dysfunction that has an acute or subacute onset and is mnifest clinical by a wide range of flucutation mental status abnormality

global cognitive impariment in thinking, memory, perception decreased atention chagne in level of consciousness agitation or decreased motor activity disturbance in sleep-wake cycle

common preseniting feaeture of fatal or serious illness can be dangerous! keep an eye on them! incredibly difficult for pts very stressful for family

who gets delirum 10-30% of hospitalized patients elderly pts post cardiotomy pts burn pts pts with pre-existing brain disease pts in drug withdrawwal pts with AIDS average age is 75 yo 'bad brains' perceptional decline polypharmacy change in sleep patterns

Don't worry about it....but lots of terms...acute brain failure, organic brain suydndrome, toxic encephalopathy

Storeis: Prodormal symptoms:

2nd year resident consult service dont' get stat paged often in lectures... beeper goes off stat paged in stairwell at end of hall....350 lb obese woman with pair fo scissors 'take the scissors away and put her to bed' no psych history--clue that delerium upper GI bleed DT...delerium tremens didn't write orders to watch for DTs...needed benzodiazapines

2nd story harvard professor tripped, broke hip seems really depressed on table newspapers from day before....piling up...reading glasses... alert...didn't know date, where was... confusion... had to talk to him...what else may be going on...

what do see? >restless, sleep disturbance, aniety, irritablilty
 * prodrome:
 * flucutating course typical
 * attentional deficits

> hyperactive > hypoactive > mixed > immediate > recent
 * altered arousal and psychomotor abnormalities
 * sleep-wake disturbance
 * impaired memory


 * disorganized thinking ,speech
 * disoriented...time >> place, rarely self

altered perceptions..can develop into delusions visual hallucainations auditory or tactile illusions

neurologic dysgraphia dysnomic aphasia consturctional abnoormalities *(clock) Motor abnormalities EEG: diffuse slowing low voltage, fast activity in hyperactive pts

emotional disturbances anxious, panic, fear, anger, sadness, depression, apathy, steroid euphoria

3 most common: Look for fluctuation, disorientation, difficulties in attention

Differential Diagnosis: Psychoses--Schizophernia, mania > EEG can be useful--normal if psychosis

Dementia: distinguish

Delerium: acute onset fluctuation lasts horus to days low or hyper-alert distractable imparied orientation for time, mistake unfamility for familiar immediate, recent memory imparied...lonong term memory okay disorganized thinking illusions, hallucinations

Dementia insidious stable over the day chronic normal alertness attention normal impovereished thinking impiaried orientation clinical moemory impairment perceptual disturbances are rare

What causes delirium: not clear best supported hypothesis is a cholinergic deficit we don't know acetylcholine is needed for attention, sleep-wake pattern loss of cholinergic neurons --> alzheimers anticholinergic agents can cause delirium physostigmine, cholinergic agent, can partially reverse delerium hypoxia, decreased blood glucose induce hypocholinergic activity, delerium

causes: don't need to know know that can be caused by almost anything physiological from book neuropsychiatry a couple mneumonic think about when on the wards next year WIMPHHH

Wernicke's encepalopathy or withdrawal H Hypertensive encepalopathy H Hypoglycemia H hypoperfusion of CNS H Hypoxemia I Intracranial bleeding or infection M Meningitis or encephalitis P Poison or medications

diagnose almost all with vital sign check and a physical exam

Longer list: I watch death Infectious > encephalitis, meningitis, syphilis Withdrawal > alchohol, barbituates, benzodiazapines Acute metabolic > acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure Trauma > heat stroke, postoperative, severe burns CNS pathology > Abscesses, hemorrhage, normal pressure hydrocephalus, seizures, stroke, tumors, vasculitis Hypoxia > anemia, CO piosoining, hyptension, pulmonary or cardiac failure Deficiencies > Vitamin B12, niacin, thaimine, hypovitaminoiss Endocrinopathies hyper- or hypoadrenocoticisim and hyper- or hypoglycemia Acute Vascular > hypertencsive encephalopathy and shock Toxins or drugs > medications, pesticides, solvents Heavy metals > lead, manganese, mercury

DRUGS THAT CAN CAUSE DELIRIUM anticholinergic agents cause delirium out there in OTC medicines...cold preparations 30% have taken benadryl! psychoactive meds...pain meds, seizure meds cardiac... admitted sweet old lady with MI, put on lidocaine out of her mind look in PDR or other reference

What happens? get better progress to stupor or coma chronic bain syndrome (dementia) mostly older patients death ?chronic deliious state

morbidity, mortality high 6 times complication rate of non-deliious pts 25 % die in 6 mo 5.5 times greater mortality

coronary care...coronary baloon pump...paralyzed... medication wore off pulled out ET tube

managing: ensure pt safe! #1! > may need restraints or someone with them or constant monitor monitor closely vital signs follow labs diagnose cause of illness may be multifactorial! infection, psychoactive drug maximize orienting things

minimize all medicaations can treat: haloperidol, risperidone, benzodiazepines (especially DT) psychosocial support and education environmental approaches--windows, etc, calendars

ICU psychosis: delirium

transient state acute brain disorder fluctuation attention disorder many causes common high morbidity and mortality mgmt diagnose underlying cause keep safe often fail to reognize it use orientation questions as screening technique