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Delirium
Psych
29
Medical
Graduate
10/25/2011

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Term
delirium def
Definition
-delirium is a transient, reversible cerebral dysfunction that has an acute or subacute onset and is manifest clinically by a wide range of fluctuating mental status abnormalities ("acute brain failure")
-in short, something acutely wrong with the functioning of the brain
Term
*delirium and medical care*
Definition
**delirium is a serious medical illness and the patient should be under direct medical care to treat the underlying cause**
Term
mental status abnormalities in delirium
Definition
-global cognitive impairment in: thinking, memory, perception
-decreased attention
-change in the level of consciousness
-agitation or decreased motor activity
disturbances in the sleep-wake cycle
Term
why is it important to know about delirium?
Definition
-it's common
-it can be the presenting feature of a fatal or serious illness
-delirious patients can be dangerous to themselves and others
-physicians often fail to recognize it
-it is stressful to patients and families

(always think about the patient's mental status!)
Term
epidemiology of delirium
Definition
-10-30% of hospitalized medical/surgical patients
-patients are usually really sick to go into delirium
-certain patient populations are predisposed to delirium
Term
patient populations predisposed to delirium
Definition
-elderly (esp. pt's with dementia)
-post cardiotomy
-burn
-preexisting brain disease
-drug withdrawal
-AIDS
Term
clinical features of delirium
Definition
-prodromal symptoms: restlessness, disrupted sleep, anxiety, irritability
-fluctuating course: moment to moment
-attentional deficits (distractable)
-altered arousal and psychomotor abnormailities
-sleep/wake disturbance
-impaired immediate/recent memory
-disorganized thinking, speech
-disorientation (time>>place)
-altered perceptions
-neurologic abnormalities
-emotional disturbances
Term
clinical features of delirium: neurologic abnormalities
Definition
-dysgraphia
-dysnomic aphasia (can't name things)
-constructional abnormalities (can't copy figures)
-motor abnormalities (unsteady gait, tremors)
-EEG changes: diffuse slowing, low voltage, fast activity in hyperactive, agitated patients
Term
clinical features of delirium: emotional disturbances
Definition
-anxiety
-panic
-fear
-anger
-sadness
-depression
-apathy
-euphoria (w/ steroid delirium)
Term
differential diagnosis of delirium
Definition
-psychoses (schizo, mania), can helped to be differentiated base of EEG (abnormal in delirium)
-dementia
Term
delirium vs. dementia: onset
Definition
delirium: acute onset

dementia: insidious, develops over time, can be very subtle
Term
delirium vs. dementia: disease course
Definition
delirium: fluctuation

dementia: stable over the day
Term
delirium vs. dementia: duration
Definition
delirium: lasts hours to days

dementia: chronic
Term
delirium vs. dementia: alertness
Definition
delirium: low or hyper-alert

dementia: normal alertness
Term
delirium vs. dementia: attention
Definition
delirium: distractible

dementia: attention is normal
Term
delirium vs. dementia: orientation
Definition
delirium: impaired orientation for time, mistake unfamiliar for the familiar

dementia: impaired orientation
Term
delirium vs. dementia: memory
Definition
delirium: immediate, recent memory impairment (often don't have memory of while they were delirious)

dementia: global memory impairment
Term
*delirium vs. dementia: thinking
Definition
delirium: disorganized thinking

dementia: impoverished thinking (unable to form thoughts/express themselves in a normal way)
Term
delirium vs. dementia: perceptual disturbances
Definition
delirium: illusions, hallucinations (often based of real perceptual confusion)

dementia: perceptual disturbances are rare
Term
pathophysiology of delirium
Definition
-not clear
-likely a cholinergic deficit
(cholinergics --> needed for thinking, sleep/wake cycle, attention...)
Term
causes of delirium
Definition
MANY!
-various deficiencies, infections, toxins, meds, etc can cause delirium
-some causes are life-threatening
Term
course of delirium
Definition
possible outcomes:

-recovery
-progression to stupor or coma
-chronic brain syndrome (dementia)
-death
(-chronic delirious state)
Term
morbidity & mortality in delirium
Definition
-both are HIGH
-increase may be due to the fact that these patients are already REALLY SICK
Term
diagnosis with CAM
Definition
Confusion Assessment Method CAM) Instrument

-bedside tool to diagnose delirium
-diagnostic algorithm based on 9 clinical features of delirium
-acute onset (feature 1) and inattention (2) must be present
-must be associated with disorganized thinking or altered level of consciousness
-takes about 5 minutes to administer
Term
evaluation of delirium
Definition
-MSE
-physical status-->most important to check at the bedside (vitals, neuro exam)
-records review: time course of behavior change, meds
-labwork
Term
labwork involved in evaluation of delirium
Definition
Basic labs: chem panel, CBC, drug/tox screen, urinalysis

Labs based on clinical presentation: EKG, CXR, EEG, brain imaging, LP, additional chemistries
Term
management of delirium
Definition
-treat underlying medical cause(s)
-assure patient/staff safety: sitters, restraints (when needed)
-close monitoring of vitals and labs
-minimize all meds
-pharmacological management
-psychosocial support and education
-environmental approached: having family, familiar items around
Term
pharmacological management of delirium
Definition
-Haloperidol
-Risperidone
-Benzodiazepines
Term
Delirium - take home points
Definition
~Delirium is transient, reversible cerebral dysfunction with acute or subacute onset, manifested clinically by a wide range of fluctuating mental status abnormalities

Important to:
-pay attention to patient's mental status to help recognize delirium early
-evaluate for potential causes
-treat underlying conditions
-intervene to keep the patient safe
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