Cognitive Disorders Flashcards
(36 cards)
Common features of Cognitive Disorders (10)
Impaired judgment Lack of initiative Hallucinations Loss of memory/recall Trouble with orientation Impaired impulse control Confabulation Emotional lability Short attention span Impaired problem solving
Delerium DSM-IV Criteria
an ACUTE, RAPIDLY progressive change in cognition characterized by INATTENTION & DISTURBANCE OF CONSCIOUSNESS in which symptoms FLUCTUATE over the course of 24 hours
- altered level of arousal
- memory impairment
- disorientation
- perceptual disturbance
- language disturbance/incoherent speech
9 risk factors for delerium
Cognitive impairment Age >70 poor functional status hearing/visual impairment dehydration sleep deprivation metabolic derangement infection polypharmacy
3 Types of Delirium & prevalence
Hyperactive (41%)
Hypoactive (11%)
Mixed disorder (48%)
Signs & sxs of delirium
Hyperactive: hallucinations, delusions, agitation, combativeness, incoherent, rambling speech, disturbed sleep-wake cycle, hypersensitivity to light/sound
Hypoactive: (subtle, often overlooked, misdxd), inattention, sedation, depressed, withdrawn, loss of appetite, affective flattening
Delirium DDx
Delirum 2* to medical condition, substance abuse/withdrawal
Substance intoxication
Substance withdrawal
Dementia
Psychiatric disorder: psychotic d/o, schizophrenia, mood d/o w/psychotic features
Malingering/Factitious d/o
Assessment of Delirium
Primary Survey: good history & physical: medical records, nursing records, medication history, outside informant mental status testing Secondary survey Thorough medical workup
Often helpful in assessment of delirium
history physical exam mental status testing CBC metabolic panel Urinalysis EKG CXR
Not always necessary in assessment of delirium but helpful if suggested by history/physical
EEG (often shows “diffuse slowing”)
CT scan
Cultures without known source
Lumbar puncture
Helpful if suggested by history/physical
MMSE includes evaluation of: (8)
Orientation to time & place Recall Registration Attention & Calculation Recall Language Repetition Complex commands
MMSE scoring/degrees of cognitive impairment
27-30: none
21-26: mild
11-20: moderate
<10: severe
Principles of Delerium tx (5)
- TREAT UNDERLYING MEDICAL ETIOLOGY
- maintain stability in patient’s environment
- avoid use of restraints
- ID/eliminate offending meds (benzos, tramadol, opiates, anticholinergics, H2 blockers [Pepcid])
- educate family & caregivers
Non-Pharmacologic Tx of delirium
- replace hearing aids/glasses
- private room
- around the clock attendant/sitter
- calm & reassuring behavior
- reorienting devices
- re-establish sleep/wake cycle
- educate family
- expedite return to familiar environment
Indications for pharmacologic tx of delirium (3)
- Severe agitation
- Combative behavior
- Behavior that severely interferes with care
Pharmocoligical Tx of Delirium (large categories)
BLACK BOX WARNING Traditional antipsychotic (Haloperidol) Atypical antipsychotics (Zyprexa, Seroquel, Risperdal) Benzos-avoid at all costs b/c of deleterious cognitive SEs
Haloperidol: class, use, MOAdministration, SEs
traditional antipsychotic (used in tx of delirium)
- available IV/IM/PO
- extrapyramidal side effects likely (txd w/Cogentin)
- prolonged QT interval
Zyprexa: class, use, MOAdministration, SEs
atypical antipsychotic used in delirium
IM/PO/SL
fewer extrapyramidal side effects (than Haldol)
less likely to prolong QT interval
Seroquel: class, use, MOAdmin, SEs
atypical antipsychotic used in delirium
PO
fewer extrapyramidal side effects (than Haldol)
less likely to prolong QT interval
Risperdal
atypical antipsychotic used in delirium
PO [in real life, also IM but not mentioned on slide]
fewer extrapyramidal side effects (than Haldol)
less likely to prolong QT interval
Antipsychotic Tx of Delirium considerations
no good alternatives use for appropriate reasons get baseline EKG correct electrolytes "start low and go slow" monitor BP/orthostatics EDUCATE FAMILY, enabling informed consent
Benzodiazepines in tx of Delirium-considerations
deleterious cognitive side effects-avoid at all costs can worsen depression over prescribed often cause delirium indicated for alcohol/drug delirium
Delirium Prevention
mainly don’ts
close monitoring/assisted living
modify known risk factors
Delirium Special Considerations
Post Operative Delirium
Sundowning
Alcohol withdrawal/Delirium Tremens
What 3 things can contribute to sundowning
precipitated by hospitalization
sensory deprivation
medications
