Neurocognitive disorders

Question 1

Define: DELIRIUM

Answer 1

Changes attributable to a medical condition, substance intoxication or withdrawal (substances of abuse, medication) etc

• acute onset
• relatively brief duration
• fluctuating course
• often reversible

Question 2

DSM 5 criteria of DELIRIUM

Answer 2

• memory deficit
• disorientation
• incoherent speech (language)
• visuospatial ability
• perceptual disturbance

• another medical condition
• substance intoxication or withdrawal (abuse/Rx)
• exposure to toxin
• due to multiple aetiologies

Question 3

Define: attention, awareness

Answer 3

ATTENTION = ability to direct, focus, sustain and shift attention

AWARENESS = orientation to the environment

Question 4

Acronym for ETIOLOGY of DELIRIUM

Answer 4

I WATCH DEATH

Infectious - encephalitis, meningitis, UTI, pneumonia, sepsis

Withdrawal - EtOH, benzos

Acute metabolic disorder - electrolyte imbalance, hepatic or renal failure

Trauma - brain injury, post-op

CNS pathology - stroke, haemorrhage, tumour, seizure disorder, Parkinson’s

Hypoxia - anaemia, cardiac failure, PE

Deficiencies/Drugs: B12, folate, thiamine

Endocrinopathies: thyroid, glucose, PTH, adrenal

Acute vascular: shock, vasculitis, HTNsive encephalopathy

Toxins - substance use, sedatives, opioids (esp morphine), anaesthetics, anti-ACh, anti-convulsants, dopamine agents, steroids, insulin, antibiotics, NSAIDs

Heavy metals: arsenic, lead, mercury

Question 5

Cardinal features of DELIRIUM

Answer 5

Sudden onset; fluctuate over course of the day

• Clouding of consciousness
• Difficulty maintaining or shifting attention
• Disorientation
• Illusions and hallucinations
• memory impairment

+/- neurological Sx ( dysphasia, dysarthria, tremor, motor changes)

Question 6

Ix to perform if pt is acutely delirious

Answer 6

Bloods:
FBE
UEC incl creatinine 
CMP (esp Ca lvld)
LFTs
random BSL

MSU + CXR to exclude infections

Question 7

DELIRIUM: Principles of Mx

Answer 7

Find the underlying cause and treat it!

1) INTRINSIC Factors
- identify and treat underlying cause immediately
- supportive measures: maintain hydration, nutrition, electrolyte balance, adequate pain relief (if necessary) & closely monitor VITALS
- stop all non-essential medications

2) EXTRINSIC factors
- ensure environment is quiet and well lit
- optimise hearing and vision
- [nurses shift]
- keep room near nurses station for closer observation (constant care if patient disruptive)
- family member for reassurance and re-orientation
- re-orientation cues suc has clocks and calendars

BIOLOGICAL = to manage anxiety, agitation, aggression, delusions and hallucinations

• consider a low dose anti-psychotic (haloperidol, new gen a/p)
• avoid benzos, unless EtOH withdrawal
• consider physical restraints if patient becomes violent

Question 8

How Dx delirium?

Answer 8

[CLINICAL Dx]

Confusion Assessment Method (CAM)

1) Acute onset and fluctuating
2) Inattention
3) Disorganised thinking
4) Altered conscious state

(Dx requires 1+2 and either 3 OR 4)