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Flashcards in Delirium Deck (40):
1

Prognosis of geriatric delirium

increased mortality in hospital/2 years post
increased morbidity
more cognitive deficits: up to 30-60% at 1 month
lingering impairment at 6 months post-cardiac surgery
less likely to achieve pre-delirium cognitive/functional baseline status, longer course of delirium
Independent risk factor to mortality/morbidity in and after hospitalization
persistent cognitive/functional deficits common in geriatric delirium
GA may lead to lingering cognitive impairments (POCD)

2

Delirium DSM5 criteria

A: disturbance in attention and awareness
B: develops over a short period of time, tends to fluctuate in severity during the day
C: additional disturbance in cognition
D: Disturbances in A/C are not better explained by another disorder
E: evidence that disturbance is a direct physiological consequence of another general medical condition

3

Hyperactive delirium

agitate
differentiate from anxiety, dementia

4

Hypoactive delirium

apathetic
differentiate from depression
less sleep-wake reversal

5

Delirium clinical features

Poor attention/vigilance
Clouding of consciousness
DIsorientation
Diffuse cognitive impariment
Poor memory
Delusions
Perceptual changes/hallucinations
Language disorder
Disorganized thinking/thought disorder
mood lability
sleep disturbances
psychomotor changes

6

Diagnostic process of geriatric delirium

24 hour observation including sleep-wake
anxiety
new incontinence
unsteady gait, falls
dysarthria/incoherence
mood/affect lability
subtle paranoia and hypervigilance
sleep disturbance - vivid dreams/nightmares!!

7

Subjective experience of delirium

"Being in a dream"
mental content more related to internal fantasy than external reality
passive
timelessness, sequence loss
loss of "self-consciousness"
loss of self-reflective awareness
Losso f appraisal of self to environment by drawing upon experience in memory
Retrospectively viewed as distressing usually, if recalled
may lead to anxiety, paranoia, and even PTSD

8

Screening for delirium

under-recognized esp in those >80 with hypoactive delirium with visual impairment and/or pre-existing dementia
NO reliable screening tool to differentiate delirium and dementia
practically: look for acute-onset/fluctuation in cognition, behaviour, etc.

9

Confusion Assessment Method

Acute onset and fluctuation AND
inattention AND
disorganized thinking OR
altered LOC
excellent sensitivity, good specificity

10

Pathophysiology of delirium general

Hypotheses:
oxygen deprivation
NT dysfunction
inflammation and cytokines
Physiologic stress on BBB/HPA

11

Generalized cortical disturbance in delirium

reduced cerebral oxidative metabolism/blood flow
Electroencephalographic showing:
- decreased alpha (fast) waves
- increased slow waves - theta, delta

degree of slowing correlates with severity of cognitive dysfunction (except alcohol withdrawal)

12

Delirium tremens cortical activity

alcohol withdrawal
increased cerebral metabolism
increased noradrenergic response
EEG: low to moderate voltage fast activity

13

Cortical arousal in delirium

Reticular activating system: ACh, NE, 5HT
Hypothalamus: his
Basal forebrain: ACh

14

Autonomic arousal in delirium

Sympathetic output (NE) - increased in delirium tremens

15

Neurochemical dysfunction in delirium

ACh: anticholinergic can induce delirium, reversed by physostigmine
DA: dopamine agonists can induce delirium - antipsychotics can treat
NE increased

?GABA decreased
?Serotonin, histamine
?Glutamate increased

16

Delirium Tremens clinical features

cessation/reduction in heavy use of alcohol
>=2 features developing within several hours - few days:
- autonomic hyperactivity
- increased hand tremor
- insomnia
- nausea/vomiting
- transient hallucinations/illusions: usually visual, may be auditory (Lilliputian hallucination)
- psychomotor agitation
anxiety
- grand al seizures

Watch for concurrent medica lillness

17

Alcohol withdrawal time course

Symptoms within:
12-24 h for withdrawal
24-48 seizures
72-96 delirium tremens

18

CIWA-Ar

delirium tremens screening
N/V
Headache
Anxiety
Paroxysmal sweats
tremors
agitation
disorientation/clouding of sensorium
visual disturbances
tactile disturbances
auditory disturbances

19

Delirium vs dementia

onset
attention usually intact in dementia
fluctuation seen in delirium
EEG markedly slowed in delirium (except alcohol)

20

Delirium vs depression

insight often present in depression

21

Delirium vs Lewy Body Dementia

infrequent symptom fluctuation
parkisonism/neuroleptic sensitivity frequently seen in LBD

22

Differential diagnosis of memory loss

Gradual onset with functional impairment> Dementia
Stepwise, sudden deterioration in cognition, slurred speech, confusion, aphasia, focal weakness: Cerebrovascular disease
Acute cognitive impairment: delirium
Complains of memory loss, decreased concentration, feeling of hopelessness: depression

23

Clinical features of behavioural variant FTD

character change and disordered social conduct features intially and throughout disease course
Instrumental functions of perception, spatial skills, praxis, memory intact/relatively well-preserved

24

FTD core diagnostic features

insidious onset, gradual progression
early decline in social interpersonal conduct
early impairment in regulation of personal conduct
early emotional blunting
early loss of insight

25

Behavioural supportive diagnostic features of FTD

decline in personal hygiene
mental rigidity, inflexibility
distractibility, impersistence
hyperorality, dietary changes
perseverative and stereotyped behaviour
utilization behaviour

26

Physical supportive diagnostic features of FTD

primitive reflexes
incontinence
akinesia, rigidity, tremor
low and labile BP

27

Speech and language supportive diagnostic features of FTD

altered speech output - aspontaneity/economy of speech, pressure of speech
stereotypy of speech
echolalia
perseveration
mutism

28

Investigations of FTD

Neuropsychology: significant impariment on frontal lobe tests in absense of severe amnesia, aphasia, or perceptuospatial disorder
Electroencephalopathy: normal on conventional EEG despite clinically evident dementia
Brain imaging: predominant frontal and/or anterior temporal abnormality

29

Predisposing factors of geriatric delirium

cognitive impariment
sleep deprivation
immobility
visual/hearing impariment
dehydration

30

DDx of causes of delirium

DIMS-R
Drugs
Infection
Metabolic disturbances
Structural insults
Retention problems

31

Drug causes of delirium

prescribed (narcotics, steroids, anticholinergics, NSAIDs)
OTC (dimenhydrinate, diphenhydramine)
drug intoxication/withdrawal (alcohol, sedative-hypnotics, narcotics

32

Infectious causes of delirium

urinary tract, lungs, skin blood

33

Metabolic causes of delirium

fluid (dehydration, hypovolemia)
electrolyte disturbances
nutrition (malnutrition, thiamine deficiency, anemia)

34

Structural causes of delirium

CV (angina, infarction, CHF)
CNS( stroke/ischemia, concussion)
pulmonary (hypoxia, e.g. COPD)
GI (bleeding with anemia, C. diff, colitis)

35

Retention causes of delirium

Urinary
constipation

36

Reducing the medication load in delirium

Discontinuing/substituting anticholinergic medications
- benadryl, gravol, hydroxyzine
benztropine
Urinary anticholinergics
AVOID amitriptyline - nortriptyline better tolerated
Avoid cimetidine in elderly
Monitor effects of steroids
Switch narcotics to: hydromorphone, oxycodone, fentanyl

37

Non-pharmacologic measures of delirium management

Minimize use of:
- physical restraints
- catheters
- room transfers
Maintain adequate nutrition, hydration
Optimize sensory input
maintain orientation
decrease enviornmental stimuli
increase mobility earlier
consider family/1:1 sitter
detect, manage pain

38

Physical restraints and delirium

Restraints necessary to prevent morbidity?
BUT can increase risk of developing delirium by 4.4 x
Additional morbidities/mortality risk
Avoid limb restraints in frail elderly!

39

Perpetuating factors of delirium in long-term care

Severity predicted by:
Absence of:
- reading glasses
- aids to orientation
- family member
- glass of water
Presence of bed rails/otehr restraints
prescription of >=2 new meds

40

Practical tips in delirium

ask specifically about vivid dreams/nightmares
visual/hearing aids
optimize sensory input
carry voice amplifier
urinary retention/bladder scanner