complications of physical disorders (delirium)

Question 1

what can the causes of confusion be divided into?

Answer 1

-Transient causes
-Enduring causes

Question 2

what does a transient cause of confusion mean?

Answer 2

A confusional state that is likely to recover the following resolution/elimination of the underlying cause

Question 3

examples of transient causes of confusion?

Answer 3

Delirium
Post-ictal confusion
Migraine
Delirium tremens
Physical ill-health and chronic illness.
Intoxication – covered in substance misuse session
Medications

Question 4

what is another name for an acute confusional state?

Answer 4

delirium

Question 5

what are the 3 most common types of delirium?

Answer 5

Hypoactive
Hyperactive
Mixed

Question 6

describe patient with hypoactive delirium

Answer 6

Hypoactive- quiet, confused, drowsy, fearful patient

Question 7

describe a patient with hyperactive delirium

Answer 7

Hyperactive- driven, wandering, agitated, shouting out and often aggressive

Question 8

describe a patient with mixed delirium

Answer 8

Hypoactive- quiet, confused, drowsy, fearful patient
Hyperactive- driven, wandering, agitated, shouting out and often aggressive
Mixed- some periods of both of the above

Question 9

who most commonly gets delirium?

Answer 9

-Associated with a physical insult or injury or environmental factors
-Older people
-Those with previous history of delirium and those with underlying cognitive deficits are more vulnerable

Question 10

Presentation of delirium?

Answer 10

Duration of delirium varies but often continues beyond the resolution of the original insult- often by weeks or months

-Rapid onset (1-2 days from precipitating insult)
-Disorientation, time, place, person
-Fluctuating confusion, diurnal variation evening and night often worse than day time
- Agitation and distress
- Inattention
- Auditory or visual hallucinations – often vivid.
- Patients may be aggressive as a result of fear and confusion

Question 11

treatment of delirium?

Answer 11

Treat underlying cause
* Reassurance and reorientation
* Low stimulus environment
* Assistance with activities of daily living during recovery
* Assistance with medications
* Use of appropriate legal measures (adults with incapacity, mental capacity act, vulnerable adult measures) to allow for treatment

• Pharmacological interventions to assist with distress, agitation and aggression. Not a cure but a supportive therapy. Consider low dose antipsychotic medications (Haloperidol, Quetiapine, Olanzapine) targeted to the timing of concerning symptoms.

Question 12

complications of delirium?

Answer 12

35-40% patients die within one year of episode of delirium

Question 13

what is Post-Ictal confusion?

Answer 13

-Abnormal condition following a seizure
-Begins when the seizure ends and ends when the patient has returned to baseline. Usually resolves within 30mins but can last for hours or days.

Question 14

when does post-ictal confusion start/ end?

Answer 14

-begins when the seizure ends
-ends when the patient has returned to baseline

Question 15

how long does it usually take for post-ictal confusion to resolve?

Answer 15

usually resolves within 30 mins but can last hours or days

Question 16

presentation of post- ictal confusion?

Answer 16

-drowsiness
-nausea
-confusion
-exhaustion

Question 17

management of post-ictal confusion?

Answer 17

supportive management and health promotion in the form of seizure prevention

Question 18

4 phases of migraine headache?

Answer 18

-Prodrome
-Aura
-Headache
-Postdrome

Question 19

what are delirium tremors due to?

Answer 19

severe alcohol withdrawal

Question 20

presentation of delirium tremors?

Answer 20

Auditory hallucinations
Visual hallucinations - often of insects of tiny things (e.g. ants, spiders, tiny people)
Tactile hallucinations – things crawling on the skin
Confusion
Disorientation
Sweating
High blood pressure

Question 21

treatment for delirium tremors?

Answer 21

-benzodiazepines
-consider fluid, electrolyte and vitamin replacement

Question 22

complications of delirium tremors?

Answer 22

-delirium tremors can be fatal due to high risk of seizures

Question 23

physical ill health and chronic illnesses that cause delirium?

Answer 23

-Encephalitis
-Hypoglycaemia
-Hypothyroidism/ hyperthyroidism
-Vit B12 deficiency
-Anaemia
-Electrolyte disturbances

Question 24

Medications that cause delirium?

Answer 24

-Analgesics (espcecially opioid medication and gabapentinoids)
-Steroids
-Benzodiazepines
-Narcotis (zopiclone, zolpidem)
-NSAIDs
-H2 receptor antagonists (digoxin, beta blockers)

Question 25

Enduring causes of delirium?

Answer 25

-Aquired brain injury
-Dementia (Alzheimer’s disease, Vasculr dementia, mixed presentations)
-Alcohol related dementia

Question 26

most common subtype of dementia?

Answer 26

Alzheimer’s

Question 27

what type of memory is typically affected in Alzheimers?

Answer 27

short term= impaired
long term= usually preserved

Question 28

findings on CT of Alzheimers?

Answer 28

atrophy most notable in the temporal lobe

Question 29

treatment for Alzheimers?

Answer 29

progression can be slowed but not ceased with Acetylcholinesterase Inhibitors (e.g. Donepezil, Galantamine)

Question 30

what is vascular dementia caused by?

Answer 30

caused by impaired blood flow to the brain leading to chronic vascular injury/ TIAs or stroke events

Question 31

what does a CT of someone with vascular dementia show?

Answer 31

a pattern of small vessel disease or stroke

Question 32

what is alcohol related dementia?

Answer 32

Neuronal damage secondary to long term, excessive alcohol consumption. Predominantly affects the frontal lobes

Severe end of a spectrum of disorders collectively names Alcohol related brain Injuries (ARBI)

Question 33

can alcohol related brain injuries be reversed?

Answer 33

yes- if a patient remains abstinent from alcohol for 9-12 months

Question 34

is codeine a good drug to use for a patient with delirium?

Answer 34

no