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Year 4 - Psychiatry > Session 05 - Delirium > Flashcards

Session 05 - Delirium Flashcards

1
Q

What is delirium?

A

An acute confusional state characterised by the rapid onset of a global but fluctuating dysfunction of the CNS.

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2
Q

What are the causes of delirium?

A

PINCH-MEE:

Pain
INfection
Constipation
Hydration

Medication (drugs)
Electrolytes (e.g. hyponatraemia)
Environment

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3
Q

What is hypoactive delirium?

A

An acute confusional state where the patient presents as withdrawn, quiet and sleepy.

They might display inactive or reduced motor activities, or seem to be in a daze.

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4
Q

What is hyperactive delirium?

A

An acute confusional state where the patients present as restless, agitated and sometimes aggressive.

They may exhibit strong emotions with fearfulness and hallucinations.

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5
Q

What is mixed delirium?

A

An acute confusional state where the patient displays signs of hypo- any hyperactive delirium.

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6
Q

What are the symptoms of hallucinations?

A
  • acute confusion
  • poorly explained, transient delusions
  • autonomic hyperactivity (sweating, tachycardia)
  • disturbance of sleep-wake cycle (patient more alert during the evening; AKA sundowning).
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7
Q

Diagnosis of delirium.

A

1) Impaired attention and awareness
2) Perceptual disturbance (e.g. visual illusions / hallucinations) or cognitive disturbance (e.g. memory / orientation deficit)
3) symptoms should develop acutely and fluctuate
4) not due to a pre-existing psychiatric disorder

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8
Q

How to assess delirium?

A
  • mental state examination
  • MOCA (cognitive assessment)
  • physical examination to find any underlying cause
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9
Q

Investigations for delirium.

A
  • bloods (FBCs, U&Es, folate, Vit-B12 and Ca2+)
  • blood culture (exclude infection)
  • urinalysis (exclude UTI)
  • ECG and CXR
  • CT head / MRI
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10
Q

Management of delirium.

A

Identify underlying cause and correct electrolyte and fluid imbalances.

Aim to make the environment as comfortable as possible and the doctors/nursing team the same.

Sedatives include short acting benzodiazepine and promethazine.

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11
Q

Distinguish between dementia and delirium:

a) onset

b) progression

c) duration

d) attention, alertness and orientation

e) sleep-wake cycle

f) speech

g) thoughts

h) perceptions

i) behaviour

A
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12
Q

What are the components of a mental state examination?

A
  • appearance and behaviour
  • speech
  • mood and affect
  • thoughts
  • perception
  • insight and judgement
  • risk
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13
Q

Appearance component of MSE.

A

Observe the patient’s general appearance:

Personal hygiene: are there any signs of self-neglect?

Clothing: are they dressed appropriately for the weather/circumstances? Are clothes put on correctly?

Physical signs of underlying difficulties: any self-harm scars or signs of intravenous drug use?

Stigmata of disease: note any stigmata of disease (e.g. jaundice).

Weight: note if they appear significantly underweight or overweight.

Objects: look around to see if the patient has brought any objects with them and note what they are.

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14
Q

Behaviour component of MSE.

A
  • engagement and rapport
  • eye contact
  • facial expression
  • body language
  • psychomotor activity
  • restlessness

Involuntary movements:
-Tremors
-Tics
-Lip-smacking
-Akathisias
-Rocking
-Posturing

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15
Q

Speech component of MSE.

A
  • rate of speech
  • quantity of speech
  • tone of speech
  • volume of speech
  • fluency and rhythm of speech
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16
Q

Define

a) mood

b) affect

A

a) patient’s predominant subjective internal state as described by them.

b) immediately expressed and observed emotion.

Affect is what you observe; mood is what the patient tells you.

17
Q

Mood component of MSE.

A

A patient’s mood can be explored by asking questions such as:

  • “How are you feeling?”
  • “What is your current mood?”
  • “Have you been feeling low/depressed/anxious lately?”

Examples of mood states
- low mood
- anxious
- angry
- enraged
- euphoric
- guilty
- apathetic

18
Q

Affect component of MSE.

A

Observe the apparent emotion reflected by the patient’s affect.

Range and mobility of affect (reactive, fixed, restricted or labile).

Intensity of affect.

Congruency of affect.

19
Q

What is

a) fixed affect?

b) restricted affect?

c) labile affect?

A

a) the patient’s affect remains the same throughout the interview, regardless of the topic.

b) the patient’s affect changes slightly throughout the interview, but doesn’t demonstrate the normal range of emotional expression that would be expected.

c) characterised by exaggerated changes in emotion which may or may not relate to external triggers.

20
Q

What are the components of thought assessment in MSE?

A

Thought form: the processing and organisation of thoughts (speed of thoughts, flow and coherence).

Thought content: abnormalities can include delusions, obsessions, compulsions, suicidal thoughts.

Thought possession: abnormalities can include thought insertion, thought withdrawal or thought broadcasting.

21
Q

Perception component of MSE.

A

The organisation, identification and interpretation of sensory information.

Abnormalities of perception include:
- hallucinations
- pseudohallucination
- illusion
- depersonalisation
- derealisation

22
Q

Define

a) hallucination

b) pseudohallucination

c) illusion

A

a) the sensory perception without external stimulus, that the patient believes is real.

b) the same as a hallucination, but the patient knows it is not real.

c) the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).

23
Q

Define

a) depersonalisation

b) derealisation

A

a) the patient feels that they are no longer their true self, and are someone different or strange.

b) a sense that the world around them is not a true reality.

24
Q

Cognition component of MSE.

A
  • orientation to time, place and person
  • attention span and concentration levels
  • short-term memory
25
Q

Give some examples of clinical tests that can be used to make a formal assessment of cognition.

A
  • Mini-Cog
  • 6-item screener
26
Q

Assessment of insight in MSE.

A

Insight, in a mental state examination context, refers to the ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal. Several mental health conditions can result in patients losing insight into their problem.

Some examples of questions which can be used to assess insight include:

  • “What do you think the cause of the problem is?”
  • “Do you think you have a problem at the moment?”
  • “Do you feel you need help with your problem?”
27
Q

Assessment of judgement in MSE.

A

udgement refers to the ability to make considered decisions or come to a sensible conclusion when presented with information. Judgement can become impaired in several mental health conditions leading to poor decision making.

You may gain an understanding of the patient’s judgement abilities as you move through the mental state examination.

You can also specifically assess judgement by presenting the patient with a scenario such as:

“What would you do if you could smell smoke in your house?”

28
Q

Components of a risk assessment.

A
  • risk to self
  • risk to others
  • risk from others
29
Q

What is the 6-item screener assessment?

A

Consists of 3 questions:
- year
- month
- day of the week

Consists of a 3 word recall:
- balloon
- cat
- kettle

Each correct response scores one point for a total of maximum of six points.

Two or more errors are considered high risk for cognitive impairment.

30
Q

What is the Mini-Cog assessment?

A

A 3-item recall test for memory:
- cat
- balloon
- kettle

A clock drawing test.

There is one point for each word remembered after the clock has been drawn, and 2 points for a normal clock.

A score ≥ 3/5 or more indicates a low likelihood of dementia.

Year 4 - Psychiatry (11 decks)

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