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Delirium may resemble psychiatric emergency - PowerPoint PPT Presentation


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Delirium may resemble psychiatric emergency. Yana M. Van Arsdale, MD, PhD. Is it delirium or psychosis?. A 67 y/o homeless single caucasian male was brought to a ER by the police Unkempt, dirty, disheveled, and smells of urine and feces Does not look at the interviewer

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is it delirium or psychosis
Is it delirium or psychosis?
  • A 67 y/o homeless single caucasian male was brought to a ER by the police
  • Unkempt, dirty, disheveled, and smells of urine and feces
  • Does not look at the interviewer
  • Does not respond to most of questions
is it delirium or psychosis3
Is it delirium or psychosis?
  • Knows his name
  • Does not know the date
  • Can not describe the events that led to his admission
  • Complains on tooth ache, requests Vicodin
is it delirium or psychosis4
Is it delirium or psychosis?
  • Appears tense & guarded
  • Considers that it might be some conspiracy around him
  • Denies any problems other than toothache
  • Denies any drug/alcohol abuse
  • Asks to let him go home
is it delirium or psychosis5
Is it delirium or psychosis?
  • UDS “+” amphetamine, opioids, THC
  • BAC neg
  • UA “+” ketones, bacteria, leukocytes
  • CBC – anemia, leukocytosis
  • CT head – old CVA
  • ECG – old MI
  • MMSE- 8/30, says he can’t read/count
definition
Definition
  • Acute confusional state
    • Transient global disorder of cognition
    • Generalized cerebral dysfunction
    • Not a disease
    • A syndrome
definition7
Definition
  • Usually reversible
  • Multiple causes
  • Presents with wide range of neuropsychiatric abnormalities
dsm iv tr criteria
DSM-IV-TR criteria
  • Disturbance of consciousness
    • Reduced clarity of awareness of the environment
    • Reduced ability to focus, sustain or shift attention
dsm iv tr criteria9
DSM-IV-TR criteria
  • A change in cognition
    • Memory deficit
    • Disorientation
    • Language disturbance
  • Perceptual disturbance
dsm iv tr criteria10
DSM-IV-TR criteria
  • Disturbance develops over a short period of time
    • Hours to days
  • Fluctuates during the course of the day
dsm iv tr criteria11
DSM-IV-TR criteria
  • Evidence from the
    • History
    • Physical examination
    • Laboratory findings
  • General medical condition (GMC)
  • Substance intoxication/withdrawal
  • Multipleetiologies
hallmark of delirium
Hallmark of delirium
  • Waxing and waning type of confusion
challenge
Challenge
  • Delirium is often unrecognized
  • Misdiagnosed
  • Medical Emergency
  • Mistaken for
    • acute psychosis
    • mania
    • depression
    • dementia/“old age”
    • dissociation
limitations of our presentation
Limitations of our presentation
  • Dementia
  • Depression
  • Epidemiology
  • Physical examination
  • Laboratory findings
  • Tx
history
History
  • Latin term meaning “off track”
  • Was recognized by Hippocrates
  • Sutton described Delirium Tremens in 1813
  • Wernicke described acute encephalopathy that bears his name
pathophysiology
Pathophysiology
  • Based on the state of arousal
  • 3 types are described:
    • Hyperactive
    • Hypoactive
    • Mixed
hyperactive delirium
Hyperactive delirium
  • Alcohol withdrawal
  • Alcohol intoxication
  • PCP intoxication
  • LSD intoxication
hypoactive delirium
Hypoactive delirium
  • Hepatic encephalopathy
  • Hypercapnea
mixed delirium
Mixed delirium
  • Daytime sedation
  • Nocturnal agitation
  • “Sundowning” phenomena
mechanism
Mechanism
  • Not understood
  • Reversible cerebral oxidative metabolism
  • Multiple transmitter abnormalities
acetylcholine
Acetylcholine
  • Crucial neurotransmitter
  • Decreased activity in the brain
  • Anticholinergic activity is increased
  • Alzheimer disease – particular susceptibility
acetylcholine22
Acetylcholine
  • Too many prescribed medications with anticholinergic activity – most common cause
  • Rx: Physostigmine salicylate (Antilirium) 1-2 mg IV/IM Q15-30’ – Tx of anticholinergictoxicity
neurotransmitters
Neurotransmitters
  • Norepinephrine
    • Alcohol withdrawal
  • Serotonin
    • Sepsis
    • SSRI
    • LSD
    • Hepatic encephalopathy
neurotransmitters24
Neurotransmitters
  • Dopamine – relieve with antipsychotic Tx
  • Glutamate
  • GABA
    • Hepatic encephalopathy – increase
    • Benzodiazepine/alcohol withdrawal - decrease
other mechanisms
Other mechanisms
  • Circadian rhythms disruption
    • Cortisol
    • Beta endorphines
    • Exogenous glucocorticoids
other mechanisms26
Other mechanisms
  • Cytokines: interleukin-1 (endogenous pyrogen) & -6
    • Head trauma
    • Ischemia
    • Toxins
    • Infection
other mechanisms27
Other mechanisms
  • Sleep deprivation
  • Psychosocial stress in brain compromise
neuroanatomy
Neuroanatomy
  • Reticular formation (RF) of the brainstem
  • Area regulates
    • attention
    • arousal
  • Locus ceruleus & its noradrenergic neurons – alcohol withdrawal
pathway
Pathway
  • Dorsal tegmental
  • Projects from the mesencephalic RF to the
    • tectum
    • thalamus
differential dx
Differential Dx
  • Schizophreniform DO
  • Schizophrenia
  • Brief psychotic DO
  • Manic episode
  • Depressive episode
  • Dissociative DO
  • Factitious DO
  • Malingering
ddx factitious do malingering
DDx: Factitious DO/ Malingering
  • Inconsistency of mental status
  • Different behavior without supervision
  • Secondary gain/ assuming sick role
  • Intentionally produced
ddx schizophreniform do
DDx: Schizophreniform DO
  • Delusions/hallucinations
    • more constant
    • better organized
  • Level of consciousness / arousal unchanged
  • Orientation – no change
ddx schizophreniform do33
DDx: Schizophreniform DO
  • VH/ tactile – not typical
  • Thought disturbances
    • loose associations
    • tangentiality
    • derailment
treatment
Treatment
  • Underlying cause
  • Precautions, including 1on 1 supervision
  • Environmental modification
    • Reorientation techniques
    • Memory cues
    • Family member present
  • Explanation of procedures
treatment35
Treatment
  • Avoid
    • Overstimulation
    • Sensory deprivation (“black-patch delirium”)
    • Physical restraints
treatment36
Treatment
  • Restraints – aggression/agitation
    • Chemical
    • Physical
  • Minimize pharmacotherapy
    • Discontinue as many medications as possible
  • Sleep
  • Fluid & nutrition
treatment37
Treatment
  • Medical Evaluation
    • conclusive - admission
    • inconclusive - observation
special concerns
Special concerns
  • Alternative medicine products use
  • Herbs use / abuse
    • Jimson weed
    • Mandrake
    • Henbane
  • Detailed drug/medications Hx – imperative
  • Delirium may be the ONLY presenting symptom
complications
Complications
  • Wandering & getting lost
  • Falls & combative behavior – injuries
  • Seizures
  • Malnutrition, fluid & electrolyte abnormalities
  • Aspiration pneumonia
  • Pressure ulcers
  • Decreased function & mobility
prognosis
Prognosis
  • Worse
    • Poor premorbid cognitive functioning
    • Previous Hx delirium
    • Brain disease
    • Multiple causes / risk factors
    • Old age
  • Better
    • High premorbid cognitive functioning
family pt education
Family/Pt Education
  • Etiology & course
    • Result of medical condition or substance
    • Rapidfluctuation of mental condition
    • Reversible / temporary – most cases
  • Risk factors – prevention in a future
family pt education42
Family/Pt Education
  • Out of proportion with premorbid behavior
  • Visit the Pt
    • One at a time
    • Provide reorientation
    • Familiar objects (photos, decorations, etc)
    • Avoid overstimulation
prevention
Prevention
  • Should be the goal
  • High risk – close monitoring
  • Multicomponentintervention
    • Sleep deprivation
    • Medical conditions
    • Cognitive impairment, etc
  • Prescribing practices – avoidpolypharmacy
legal pitfalls failure to
Legal pitfalls:Failureto…
  • Recognize alcohol withdrawal in the Pt with altered mental status (AMS) &/or abnormal vital signs
  • Tx the Pt with AMS
  • Exclude other etiologies of delirium
  • Admit
legal pitfalls
Legal pitfalls
  • Determining whether the PT has the capacity to make informed decision
  • Capacity is usually not globally impaired unless impairment is severe
  • Competence is a legal term, determined by the judge, not the physician
legal pitfalls46
Legal pitfalls
  • Surrogate decision-making laws - differ from state to state
  • Elopement precautions – must be taken (The Pt might be lost or/& injured)
  • Fall / Suicide precautions
  • Leaving the hospital AMA- urgent legal assistance