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27 Cards in this Set
- Front
- Back
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Delirium Definition |
1. Disturbance of cognition 2. Fluctuation 3. Reduced awareness 4. Change in psychomotor behavior |
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Delirium: Disturbance of cognition |
Reduced ability to direct, focus, sustain, or shift attention Sudden profound impact on other domains Often unable to maintain coherent stream of thought or action Highly distractible |
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Delirium: Fluctuation |
Level of attention and orientation to the environment throughout the day Somnolence and excessive alertness, intense agitation, frenzied excitement + hyperactive and - hypoactive features Disturbance of mood and sleep-wake cycles |
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Delirium: Reduced Awareness |
Disorders of perception MIsperceptions Sensory illusions Delusions and/or hallucinations are often erratic and nonsystematic |
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Delirium: Changes in psychomotor behavior |
hyperkinetic, hypokinetic or mixed presentation Hyper - Increased motor activity, restlessness, stereotyped behaviors, and psychomotor agitation Hypo - Lethargy, lack of initiation, and slow RT |
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Encephalopathy |
A nonspecific term used to describe any medical condition impacting brain's function Both acute and chronic conditions |
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Delirium: common causes |
I WATCH DEATH Infection Withdrawal Acute Metabolic TBI CNS pathology Hypoxia Deficiencies (Nutritional) Endocrinopathies Acute vascular Toxins or drugs Heavy Metals |
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Delirium: Neuropathology |
- Decrease in Ach - cholinergic deficiency hypothesis - contributes to impairments in attention and memory - reversed by eserine - Excess dopamine or enhanced receptor site sensitivity - thought to cause hallucinations - Levodopa can cause - Disruption or overexcitation of serotonergic systems may cause hallucinations and emotional lability. - agitation, myclonus, hyperreflexia, diaphoresis, tremor, diarrhea, incoordination, fever (serotonin syndrome) |
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Delirium: Predisposing Factors |
Age, medical comorbidities, cognitive and functional impairments, depression, sensory loss or dysfunction, respiratory failure, myocardial infarction, infection -Preexisting brain disease: reduced cognitive reserve -age: change in vasculature, decreased Ach, increased MAOi -comorbid physical problems: sleep deprivation, sensory impairment, immobility -medical comorbidities: chronic or poorly controlled conditions |
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Delirium: Precipitating Factors |
Major surgery, anticholinergic drugs, drug withdrawal, infections, iatrogenic complications, metabolic derangements, pain -postoperative states and complications such as hyponatremia -Acute injuries: or medical procedures that do not directly affect the CNS that result in metabolic issues |
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Delirium Rates |
1-2% of population Young - toxic iatrogenic drugs or illicit drug use Older - med side effects; 35% after vascular 40-60% after hip 50% experience permanent cog impairment after resolution 80% of patients experience in stages prior to death |
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Delirium: Severity |
Life threatening condition *multisystem organ failure *Sustained autonomic hyperarousal and/or storms despite treatment *Status epilepticus or multiple treatment-resistant seizures *Wernicke's encephalopathy and/or delirium tremens *Chronic, uncorrected metabolic distrubance or physiologic condision |
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Delirium: Course Abrupt Onset |
TBI, stroke, sudden event results in immediate confusion and behavioral changed. Typically steady recovery |
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Delirium: Course Slow-onset/fluctuating course |
Develop over hours or days (developing metabolic disturbance) Sx often wax and wane, islands of lucidity, wide variety of outcomes |
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Delirium: Assessment |
* Assume reversible and work together to ID and reverse etiology *Determine if MD's reviewed meds and interactions *Determine if MD's checked for infection or medical cause *Review clinician and collatoral reports for infection or medical cause *Review labs *Review neuroimaging and abnormal EEG *Monitor confusion with periodic reassessment |
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Delirium: Psychiatric Features |
Consciousness and cognition not as severely impaired as in delirium Hallucinations and delusions typically more consistent and systematic compared to delirium |
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Delirium: Treatment |
Correct all possible causative factors ER - give thiamine followed by glucose Adequate hydration, nutrition, airway Vitals monitored closely Prevent complications |
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Delirium: NP expectations |
bedside exam and bg info IQ - decreased fxn, some return to baseline others have decreased fluid intelligence Attn - sig difficulty sustained, moments of clarity, distractible PS - mod/sev impairment; deficits apparent during lucid moment on formal evaluation Lang - fluent aphasia in some mute, dysnomia VS - commonly affected and likely due to decreased attn/EF Mem - disorientation of time/place common, mem impaired EF - always impaired, decreased flex, judge, reason, disorganized thoughts SM - changes in reflexes and tone Emo - dramatic changes |
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Delirium: Considerations |
Safety Driving School Capacity Meds Family Functional issues Rehabilitation |
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Formication Hallucinations |
Bugs on skin Often reported in drug withdrawal When unilateral suggests focal parietal or thalamic lesions |
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Visceral Hallucinations |
Sensations that are believed to stem from internal organs Typically unpleasant and difficulty to localize Psychiatric or neurologic conditions |
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Hypnagogic Hallucinations |
Occur in the presence of falling asleep |
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Hypnopompic Hallucinations |
Occur in process of awakening Often coincide with sleep paralysis |
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Metamorphopsia |
Perception that one's body is changing in size or shape. Alice in wonderland system |
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Misidentifications |
A fixed delusional belief that objects, people, or places have been duplicated Capgras Syndrome - belief that a person has been replaced by an imposter Reduplicative paramnesia - belief that a place has been replaced and duplicated. |
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Peduncular Hallucinations |
Vivid, motion-filled hallucinations that include the perception of small objects, animals, people, or familiar landscapes. Often pleasant or entertaining but can become anxiety provoking Typically associated with lesions involving the posterior circulation |
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Release Hallucinations |
Occur as consequence of sensory loss and subsequent disengagement of higher cerebral systems Palinopsia - visual image continues to appear to be re-experienced hours or days after it is no longer present |
