Ch 27 Delirium

Question 1

Delirium definition

Answer 1

Reversible, acute onset condition that develops over a short period of time.

Results in fluctuating and transient global cognitive dysfunction

Question 2

Is delirium considered a syndrome or a specific disease process or disorder?

Answer 2

Syndrome because of the many causes of delirium

Question 3

Diagnostic criteria for delirium

Answer 3

Disturbance of attention and awareness.
Acute onset and fluctuation.
Other cognitive impairments.

Question 4

Disturbance of attention and awareness means?

Answer 4

Reduced ability to direct, focus, sustain, shift attention. Reduced orientation to the environment

Question 5

Acute onset in fluctuation means?

Answer 5

Hallmark features

Three subtypes. Hyperactive, hypoactive, mixed.

Question 6

Other cognitive impairments means?

Answer 6

Additional disturbance in cognition:

Perception disorders, delusions, hallucinations, Psychosis.

Question 7

Difference between encephalopathy and delirium.

Answer 7

used interchangeably
But encephalopathy describes both acute and chronic conditions.

Delirium is an acute condition

Question 8

Delirium differential diagnosis acronym

Answer 8

I WATCH DEATH

Question 9

DELIRIUM ACRONYM I WATCH DEATH MEANS

Answer 9

Infection. 
Withdrawal. 
Acute metabolic. 
Trauma. 
CNS pathology. 
Hypoxia. 
Deficiencies. 
Endocrine northeast. 
Acute vascular. 
Toxins or drugs. 
Heavy metals.

Question 10

Contributions to delirium

Answer 10

Neurotransmitter system dysfunction.
CNS response to inflammation.
Hypothalamic pituitary adrenal axis dysregulation.
Direct cerebral insults or injury.

Question 11

Dysfunction related to delirium occurs at what level

Answer 11

Cellular and neurotransmitter level

Question 12

Which mechanisms are most likely being disrupted in delirium

Answer 12

Reticular activating system, subcortical, cortex

Question 13

Neurotransmitters involved in delirium

Answer 13

Acetylcholine

• for attention, memory, arousal.
• High level of Acetylcholine is related to delirium

Dopamine

• excess dopamine causes hallucination.
• Bupropion can exacerbate delirium
• Levodopa can cause hallucination, agitation

Serotonin
- disruption or over excitation of serotonergic systems can cause hallucination and emotional lability

Question 14

Risks factors for delirium

Answer 14

Predisposing factor. 
Old age, 
dementia, 
severity of physical illness, 
multi drugs, 
metabolic disturbances, 
depression, 
sensory loss,
respiratory problems, 
myocardial infarction,
infection
Sleep deprivation, 
sensory impairment,
mobility, 
functional decline, 
dehydration, pain, 
medical comorbidity.

Question 15

Independent risk factor associated with delirium

Answer 15

Age is an independent risk factor

Question 16

Precipitating factors for delirium

Answer 16

Surgery, side effects of drugs, drug withdrawal, infection, metabolic derangement, pain.

Question 17

Prevalence of delirium

Answer 17

14% age 85 and above

Question 18

Types of delirium and prevalence in critical care settings

Answer 18

Most common is

1. mixed type delirium,
2. hypoactive,
3. hyperactive

Question 19

Type of delirium and prevalence and non-critical care setting

Answer 19

Hypoactive delirium is more common

Question 20

Common causes of delirium in elderly

Answer 20

Infection

Question 21

Cause of delirium in young adults

Answer 21

drug abuse and withdrawal

Question 22

Common causes of delirium and children

Answer 22

Medication side effects

Question 23

Percentage of people experiencing permanent cognitive impairment following resolution of delirium

Answer 23

Up to 50%

Question 24

Other morbidity of delirium

Answer 24

Impulsively, picking up skinner clothes, agitation all leading to an unintentional injury

Question 25

Chance of death who survived delirium

Answer 25

35 to 40%

Question 26

Presentation of delirium - two general courses

Answer 26

1. Abrupt immediate onset. Can occur with moderate or severe TBI or stroke. Neurological event causes confusion and behavioral change. ``` 2. Slow onset or fluctuating course prodromal period, symptoms develop over hours or days. islands of lucidity Syndromes wax and wane. Mild to moderate cognitive impairment. ```

Question 27

What do EEG findings show in delirium

Answer 27

Typically abnormal EEG especially in metabolic delirium

Question 28

What is an important cognitive function to assess for in differentiating delirium

Answer 28

Attention and sustained attention.

Question 29

Characteristics of hallucinations and delusions associated with delirium

Answer 29

Delirium, hallucinations and delusions are unsystematic, variable, can be formed and unformed. In psychosis. they are typically formed with distinct shapes, objects, people, scenes.

Question 30

Examples of hallucinations and delusions in delirium

Answer 30

Formication hallucination. - Feeling of bugs crawling over the skin. - Suggest drug withdrawal delirium.

Question 31

acute interventions at the ED with delirium?

Answer 31

IV fluids thiamine glucose

Question 32

examples of medications used in delirium

Answer 32

benzos - counter alcohol withdrawal neuroleptics - address hallucination and sleep problems GABA targeted drugs for agitation

Question 33

charles bonnet syndrome

Answer 33

visual hallucination in people who lose eyesight. perception of faces, small objects, people aware that they are not real

Question 34

Autonomic storms

Answer 34

reaction to autonomic nervous system to severe injury, metabolic disturbance, overstimulation HTN, tachycardia, diaphoresis common cause - SCI, substance use, meds side effects, TBI

Question 35

neuroleptic malignant syndrome

Answer 35

complication following neuroleptic use - muscle rigidity - pallor - dyskinesia - hyperthermia - incontinence - unstable blood pressure - tachycardia - pulmonary congestion

Question 36

Delirium tremens

Answer 36

global confusion hallucination autonomic hyperactivity

Question 37

Wernicke's encephalopathy

Answer 37

confusion (ocular) abnormalities. ataxia of the eye - cannot control eye voluntarily AOC - cortez

Question 38

serotonin syndrome symptoms

Answer 38

``` tremor diarrhea diaphoresis mental status changes hyperreflexia fever incoordination ```

Question 39

Vitamin b12 deficiency sx

Answer 39

Anemia, weakness, fatigue, mood changes, memory loss, disorientation. Impaired recognition of pressure, difficulty walking, tingling or numbness, irritability, depression, impaired attention, hallucinations, impaired proprioception

Question 40

definition of embolic shower

Answer 40

pattern of multiple, acute cortical strokes in different vascular territories

Question 41

Coronary artery bypass graft cardiac valve replacement surgery are usually associated with what condition

Answer 41

Embolic shower

Question 42

Hyponatremia

Answer 42

electrolyte disturbance sodium concentration low water accumulates in the body at a faster rate than it can be excreted can lead to cerebral edema (e.g. congestive heart failure, polydipsia) 25% cases are postoperative

Question 43

What factor is most predictive of persistent cognitive impairment and complications of delirium

Answer 43

Length of delirium

Question 44

Hyperatremia

Answer 44

electrolyte disturbance sodium concentration too high caused by dehydration or conditions that result in excessive water loss (.e.g diarrhea, gastroenteritis) causes dehydration --> delirium

Question 45

types of hallucinations

Answer 45

formication - bugs crawling over skin hypnagogic - when falling asleep hypnopompic - in the process of awakening, together with sleep paralysis lilliputian - formed visual hallucination, objects seen smaller than in real life metamorphorsia - one's body changing in shape or size (alice in wonderland) misidentification - objects, people being duplicated peduncular - vivid, motion filled. perception of small objects. pleasant and entertaining (POSTERIOR STRUCTURES) Release - occurs 2/2 sensory loss (Charles bonnet, phantom limb) Visceral - sensations stemming from internal organs, unpleasant, hard to localize