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Delirium may resemble psychiatric emergency

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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Delirium may resemble psychiatric emergency

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  1. Delirium may resemble psychiatric emergency Yana M. Van Arsdale, MD, PhD

  2. 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

  3. 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

  4. 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

  5. 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

  6. Definition • Acute confusional state • Transient global disorder of cognition • Generalized cerebral dysfunction • Not a disease • A syndrome

  7. Definition • Usually reversible • Multiple causes • Presents with wide range of neuropsychiatric abnormalities

  8. DSM-IV-TR criteria • Disturbance of consciousness • Reduced clarity of awareness of the environment • Reduced ability to focus, sustain or shift attention

  9. DSM-IV-TR criteria • A change in cognition • Memory deficit • Disorientation • Language disturbance • Perceptual disturbance

  10. DSM-IV-TR criteria • Disturbance develops over a short period of time • Hours to days • Fluctuates during the course of the day

  11. DSM-IV-TR criteria • Evidence from the • History • Physical examination • Laboratory findings • General medical condition (GMC) • Substance intoxication/withdrawal • Multipleetiologies

  12. Hallmark of delirium • Waxing and waning type of confusion

  13. Challenge • Delirium is often unrecognized • Misdiagnosed • Medical Emergency • Mistaken for • acute psychosis • mania • depression • dementia/“old age” • dissociation

  14. Limitations of our presentation • Dementia • Depression • Epidemiology • Physical examination • Laboratory findings • Tx

  15. History • Latin term meaning “off track” • Was recognized by Hippocrates • Sutton described Delirium Tremens in 1813 • Wernicke described acute encephalopathy that bears his name

  16. Pathophysiology • Based on the state of arousal • 3 types are described: • Hyperactive • Hypoactive • Mixed

  17. Hyperactive delirium • Alcohol withdrawal • Alcohol intoxication • PCP intoxication • LSD intoxication

  18. Hypoactive delirium • Hepatic encephalopathy • Hypercapnea

  19. Mixed delirium • Daytime sedation • Nocturnal agitation • “Sundowning” phenomena

  20. Mechanism • Not understood • Reversible cerebral oxidative metabolism • Multiple transmitter abnormalities

  21. Acetylcholine • Crucial neurotransmitter • Decreased activity in the brain • Anticholinergic activity is increased • Alzheimer disease – particular susceptibility

  22. 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

  23. Neurotransmitters • Norepinephrine • Alcohol withdrawal • Serotonin • Sepsis • SSRI • LSD • Hepatic encephalopathy

  24. Neurotransmitters • Dopamine – relieve with antipsychotic Tx • Glutamate • GABA • Hepatic encephalopathy – increase • Benzodiazepine/alcohol withdrawal - decrease

  25. Other mechanisms • Circadian rhythms disruption • Cortisol • Beta endorphines • Exogenous glucocorticoids

  26. Other mechanisms • Cytokines: interleukin-1 (endogenous pyrogen) & -6 • Head trauma • Ischemia • Toxins • Infection

  27. Other mechanisms • Sleep deprivation • Psychosocial stress in brain compromise

  28. Neuroanatomy • Reticular formation (RF) of the brainstem • Area regulates • attention • arousal • Locus ceruleus & its noradrenergic neurons – alcohol withdrawal

  29. Pathway • Dorsal tegmental • Projects from the mesencephalic RF to the • tectum • thalamus

  30. Differential Dx • Schizophreniform DO • Schizophrenia • Brief psychotic DO • Manic episode • Depressive episode • Dissociative DO • Factitious DO • Malingering

  31. DDx: Factitious DO/ Malingering • Inconsistency of mental status • Different behavior without supervision • Secondary gain/ assuming sick role • Intentionally produced

  32. DDx: Schizophreniform DO • Delusions/hallucinations • more constant • better organized • Level of consciousness / arousal unchanged • Orientation – no change

  33. DDx: Schizophreniform DO • VH/ tactile – not typical • Thought disturbances • loose associations • tangentiality • derailment

  34. Treatment • Underlying cause • Precautions, including 1on 1 supervision • Environmental modification • Reorientation techniques • Memory cues • Family member present • Explanation of procedures

  35. Treatment • Avoid • Overstimulation • Sensory deprivation (“black-patch delirium”) • Physical restraints

  36. Treatment • Restraints – aggression/agitation • Chemical • Physical • Minimize pharmacotherapy • Discontinue as many medications as possible • Sleep • Fluid & nutrition

  37. Treatment • Medical Evaluation • conclusive - admission • inconclusive - observation

  38. 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

  39. Complications • Wandering & getting lost • Falls & combative behavior – injuries • Seizures • Malnutrition, fluid & electrolyte abnormalities • Aspiration pneumonia • Pressure ulcers • Decreased function & mobility

  40. Prognosis • Worse • Poor premorbid cognitive functioning • Previous Hx delirium • Brain disease • Multiple causes / risk factors • Old age • Better • High premorbid cognitive functioning

  41. 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

  42. 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

  43. Prevention • Should be the goal • High risk – close monitoring • Multicomponentintervention • Sleep deprivation • Medical conditions • Cognitive impairment, etc • Prescribing practices – avoidpolypharmacy

  44. 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

  45. 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

  46. 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

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