Etiology
Drugs that induce delirium
Anticholinergics
Benzodiazepines, barbiturates
Antidepressants and antipsychotics (especially those with anticholinergic activity, e.g., quetiapine)
Antihistamines (particularly in older patients)
Main manifestacion of delirium
acute (hours to days) alteration in the level of awareness and attention.
How do you diagnose delirium?
clinical diagnosis:
- DSM5
- CAM (confusion assessment method)
Mainstay management:
treatment of underlying condition
what are the 3 types of delirium
hypoactive delirium, hyperactive delirium, mixed type
Most common cause of delirium (NOT in older patients)
Metabolic causes
What other symptoms can be in an episode of delirium
Disorganized thinking
Illusions
Hallucinations (mostly visual)
Cognitive deficits (e.g., memory)
Reversal of the sleep-wake cycle
Emotional lability
Agitation, combativeness
Alterations in psychomotor activity may occur
What features does the CAM evaluate?
1) acude onset with fluctuation course ( Change in mental status from baseline, Fluctuating level of consciousness, attention, speech, and/or disordered thinking)
2) inattention (The patient has trouble focusing, keeping track of the conversation, or can be easily distracted)
3) altered consciousness (hypervigilant, Drowsy, lethargic, stuporous, or comatose)
4) thinking is disorganized (The patient's speech is unclear, they seem incoherent, or the flow of ideas is illogical).
Diagnosis of delirium requires features 1 and 2 PLUS either feature 3 or 4.
Main non pharmacologic ways to reduce confusion
Reorient the patient to time, place, and person (3 times min)
Initiate cognitive stimulation therapy to improve cognitive function.
what differentiates hypoactive and hyperactive delirium
hypoactive: decreased psychomotor activity
hyperactive: increased psychomotor activity (agitation)
Most common cause of Delirium in older patients
UTI
do the symptoms fluctuate or are they the same the whole day?
symptoms worsen in the evening (termed sundowning).
What are the criteria for delirium in the DSM- 5?
- Attention and awareness are impaired.
- Acute onset over hours or days with waxing and waning severity
- ≥ 1 additional disruption in cognition
- The condition fulfills the following criteria: Absence of preexisting dementia, coma, or severely reduce responsiveness, Evidence of an organic underlying cause
What are some reversible causes of agitation that can be easily treated in patients with acute dementia? (non pharmacologic)
dehydration, hunger, pain, hypoxia, or urinary retention.
hyperactive delirium
Name 5 different etiologies that can produce
Constipation
Urinary retention
Major surgery
Trauma (e.g., hip fracture, traumatic brain injury)
Pain
Sleep deprivation
etc
Are the symptoms reversible ?
yes
Main differential diagnoses:
Síndrome confusional agudo,y la psicosis.
Most common antipsychotic agent used
haloperidol.
what type of delirium is most common in older population
hypoactive delirium