Block 3 PSYCH Exam -- Delirium (#4)
Terms
undefined, object
copy deck
- Why should delirium be discussed? (4)
-
Most common PSYCH diagnosis
Carries highest mortality of PSYCH diagnoses
Is often iatrogenic
Is often misdiagnosed of ignored - Prevalence of delirium in medical/surgical inpatients
- 15 - 25%
- Delirium pts. have a 6 times greater risk of getting what (2)?
-
Decubiti
Aspiration pneumonia -
Which is more reversible?
Dementia or Delirium - Delirium
-
Which is more chronic?
Dementia or Delirium - Dementia
- Major DSM characteristics of delirium (5)
-
Disturbance of consciousness
Reduced ability to sustain or shift attention
Change in cognition or development of perceptual disturbance
Develops over a SHORT period of time
Waxes and wanes throughout course of the day - Throughout a given day, what happens to the symptoms of delirium?
- They wax and wane
- What USED TO BE the focus of a diagnosis of delirium?
-
Inability to maintain attention
The focus has shifted to being a disturbance in consciousness - What group of antibiotics has been known to cause psychotic symptoms?
- Fluoroquinolones
- What Delirium ISN'T (3)
-
Dementia
Depression
Schizophrenia - What are the most common early findings of delirium on MMSE (2)?
-
Impaired attention/concentration
Impaired short-term memory (3 object recall) - Why does a normal MMSE NOT exclude delirium?
- Remember, symptoms can wax and wane
- What are the predisposing factors for delirium (5)?
-
Brain injury/damage
Severe burn
Post-operative state
Elderly
Drug withdrawal - Delirium in the elderly is most often due to what (2)?
-
Concurrent illness
Medications - Why are elderly more sensitive to medications (6)?
-
Decreased neuronal mass
Decline in ACh
Decline in DA
Decreased lean body mass
Increased body fat --> Wider distribution & slower clearance
Decreased hepatic metabolism --> longer half-life - Concurrent illness in elderly pts. can cause what problems (4)?
-
Polypharmacy
Malnutrition
Decreased GFR --> decreased renal clearance of drugs
Decreased hepatic metabolism - % of post-cardiotomy pts. who are delirious
- 15 - 70%
- What may reduce risk of post-cardiotomy delirium by as much as 50%?
- Pre-operative PSYCH interview
- Major RFs for post-cardiotomy delirium include (5):
-
Age
Time on bypass
Increased CNS adenylate kinase
Decreased CO
Complexity of procedure - % of burn patients who are delirious
- 18 - 30%
- What is the most frequent neuropsychiatric complication of HIV?
- Delirium
- Mnemonic for Insults that can lead to delirium
- I WATCH DEATH
- 'I' part of "I WATCH DEATH"
- Infectious
- 'W' part of "I WATCH DEATH"
- Withdrawal
- 'A' part of "I WATCH DEATH"
- Acute metabolic
- 'T' part of "I WATCH DEATH"
- Trauma
- 'C' part of "I WATCH DEATH"
- CNS disease
- 'H' part of "I WATCH DEATH"
- Hypoxia
- 'D' part of "I WATCH DEATH"
- Deficiencies
- 'E' part of "I WATCH DEATH"
- Environmental
- 2nd 'A' part of "I WATCH DEATH"
- Acute vascular
- 2nd 'T' part of "I WATCH DEATH"
- Toxins/drugs
- 2nd 'H' part of "I WATCH DEATH"
- Heavy metals
- Important common effect of many medications assoc. w/ delirium
- Anti-cholinergic effect
- Hepatic failure may affect this, contributing to delirium
- Na/K-ATPase pump
- Renal failure's contribution towards delirium (2)
-
Decreased renal clearance of drugs
Increased permeability of the BBB - These 3 conditions can lead to changes in brain water volume
-
Diabetic Ketoacidosis
Hyperosmolar state
Hyponatremia - This is usually NOT enough on its own to cause delirium, but it can contribute
-
Lack of novel stimulation
(sensory deprivation) - How is cerebral metabolic activity changed in delirium?
-
It is REDUCED
Reflected in decreased EEG background activity -
What 3 conditions are exceptions to reduced EEG activity in delirium?
How do these show up on EEG? -
Delirium Tremens (DTs)
HYPERthermia
Drug-induced state (ie PCP)
LOW voltage, FAST activity
(as compared to diffuse slowing) - How can BDZs make delirium worse (2)?
-
Can make pt. more agitated
May worsen confusion (particularly in elderly) - How can Antipsychotics make delirium worse (3)?
-
Can lower SEIZURE threshold
Can worsen SEDATION
Can worsen agitation (paradoxically)
NEED to watch out for neuroleptic malignant syndrome - How can Antidepressants make delirium worse (1)?
-
Can worsen confusion
NOTE: especially so w/ TCAs - What types of Antidepressants are especially bad in delirium?
- TCAs
- What medicine is commonly used for agitation NOT due to drug withdrawal?
-
Haldol
NOTE: atypical anti-psychotics are an alternative
(Ex. Ripseridone, Quietapine) - Symptomatic management for delirium pts. includes (4)
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Placing near nursing station
Frequent reorientation by family, nursing staff, etc.
Discontinuation of ALL non-essential meds
Daily labs and physicals -
How is Haldol administered to delirium patients?
(timing of doses) -
Initially, every half-hour until pt. is calm
Eventually, daily dose is consolidated
Ultimately, pt. is tapered off of it - What type of med is given to pts. who don't respond to Haldol?
- Benzodiazepines
- What needs to be watched for when giving BDZs to delirium pts. (2)?
-
Worsening of agitation or confusion
Respiratory depression -
How are BDZs administered to delirium patients?
(timing of doses) -
Bulk of the dose is given at night
(1/3 in AM, 2/3 in PM) - What is the initial focus in treating a delirium pt.?
-
Diagnosing and treating the underlying conditions causing the delirium
Focus more on conditions that increase morbidity/mortality