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delirium4
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Morning ReportSteve Hart4/19/2006
Case Presentation77 y/o AAF with ESRD presents to ED with lower extremity weakness x 1-2 days and elevated blood pressure.Feeling generally weak, now unable to ambulateOff BP meds for about a weekBP controlled with DialysisHeadachesPoor visionSome SOB and coughingPer social worker and daughter, mental status changed from baseline
PMHxHTNGlaucomaCataractAnemiaRecent AV graft infection
Social HxLives at home with daughterQuit smoking in 50s
Allergies noneMedsLisinoprilAranespXalatin eye dropsPhosloNephrocapsZocorAspirin
VitalsT 97.1 HR 79 R 14 BP 175/69 Pox 98% 2L
Physical ExamGen Alert, oriented? Female, HEENT PERRLA, EOMI, MMMNeck JVD, nl thyroidChest bilateral rhonciCV RRR, nl S1 and S2, no edema, no bruitsAbd soft, NT/ND, no HSMExt no E/C/CNeuro equal/symetric +1 reflexes., CN intact, nl cerebellar signs, +5 strength in UE, -5 in LE Neg Rhomberg
Labs138 96 73.7 33 2.5 90 13.6 5.3 218 41.5 Ca 9.7CKMB 1.8Trop I 0.05
EKG NSR, No ST changesCXR NADUA: 1.006, 8.5, prot 100, occ bact, LE large, 27 WBCDiff: N65 L20 M10
ImagingHead CTSmall vessel disease with age indeterminate infarcts in internal capsule. Possible subacute on old?
MRI Headmoderate deep and sub-cortical ischemic white matter changes non acuteBilateral patchy ischemic foci in the lentiform nucleus and pons. No intracranial mass lesionremote micro hemorrhage in the right posterior inferior aspect of the thalamus
Problem ListGeriatricWeakness, ambulatory only with assistance - newRecent decline in mental statusHTN, uncontrolledESRDUTIImpaired visionSOB, hypoxicSmall vessel disease, lacunar infarcts
Hospital CourseDay 1Started on routine SQ heparin and pepcid on admissionMI ruled out with serial enzymes and EKGsCultures negative, no empiric antibioticsRemained afebrileSOB and hypoxia relieved with dialysisBlood pressure poorly controlledNeurology consulted for mental status changes
Hospital CourseMental Status quickly deterioratedHallucinationsFluctuating mental statusAlert but not oriented at timesUnable to concentrateTangential thoughtsundowning Patient placed in restraints
Delirium
DeliriumDefinitionreduced ability to focus, sustain, or shift attention change in cognition or the development of a perceptual disturbance Acute onset (hours to days)Identifiable cause
EpidemiologyAt admission prevalence 14-24% Hospitalization incidence 6 to 56%15-53% geriatric patients post-op70-80% older patients in ICU60% nursing home will have at some time83% of geriatric patients prior to death
Delirium.Why should I care?Mortality rate in hospitalized patients 22-76% One year mortality rate is 35-40%Prolongs hospital courseIncreased cost of care in hospitalIncreases likelihood of disposition to nursing home, functional decline and loss of independence
More reasons to careStrong association with underlying dementiaFrequently, patient may never return to baseline or take months to over a year to do soDelirium is often the sole manifestation of serious underlying disease
PathophysEEG shows diffuse cortical slowingNeuropsyc and imagingDisruption of higher cortical functionPrefrontal cortexSubcortical structuresThalamusBasal gangliaFrontal and temporoparietal cortex fusiform cortexLingual gyriEffect greatest on non-dominant side.
InvolvesNeurotransmissionInflammationChronic stressPathogenesis
NeurotransmissionCholinergic deficiencyAnticholinergics can precipitate deliriumSerum anticholinergic activity increased in those with deliriumCholinesterase inhibitors can reverse this effectDopaminergic excessNeuropeptides, endorphins, serotonin, NE, GABA may play a role.Pathogenesis
PathogensisCytokinesInterleukins and interferonsOften elevated in DeliriumHave known strong CNS effectsPrimary role sepsis, bypass surgeries, dialysis, cancers
PathogensisChronic stressUntreated pain / analgesia are strong risk factorsElevated cortisol assoc with delirium
Risk FactorsUnderlying brain diseaseDementiaStrokeParkinsonsAdvanced AgeSensory ImpairmentBladder Caths
DifferentialPsychiatric IllnessDepressionmaniaDementiasNonconvulsive status epilepticusEspecially in ICUWernickes aphasiaOccipital lesions(cortical lesions and confabulations)Bifrontal lesions (tumors or trauma)
DiagnosisClinical
Step #1 Recongnize the disorder
Step #2 - Uncover underlying medical illness
RecognizeOften unrecongnized, >70% of cases
Behavioral or cognitive issues often wrongly attributed to age, dementia or other mental disorders
determine acuity of change in mental status.if no historian available, one should assume acute and delirious until proven otherwise
RecognizeDisturbance in consciousness and alterned congnitionConsciousnessAttention poorSubtle loss of mental clarity initiallyPatient isnt acting rightDistractabilityTangential or disorganized thoughtAcute/subacute onsetFluctuating course throughout a day
RecongnitionCongitionMemory lossDisorientationDifficulty with language and speechPerceptual disturbancesDelusionsHallucination
AssessmentFormal mental status evaluation in all geriatric patients (ie. MMSE or CAM)
Arouse all older patients daily to evaluate hypoactive form of delirium
Search for causes of delirium
D Drugs, Drugs and toxins, tooE Eyes, earsL Low O2 states (MI, ARDS, PE, CHF, COPD, stroke, shock)I InfectionR Retention (of urine or stool). RestraintsI IctalU Underhydration, UndernutritionM Metabolic (hypo/hyper glycemia, calcemia, uremia, liver failure, thyroid disorders)Causes
Other CausesFoley catheterInvasive procedureSleep deprivationPain
DrugsAccounts for 30% of all casesCommon culpritsAnti-histaminesAnti-cholinergicsAntibioticsSome antidepressantsDopamine agonistsHypoglycemicsBenzosOpiates
PatientPoor visionEvidence of old and recent strokesInfection - UTIRestraintedMultiple medicationsPepcid started on admissionESRDHypoxia
TreatmentCorrect all identifiable causesDelirium is usually multifactorialCorrection of multiple causes is often necessary for recoveryPharmacologic if neededAntipsychoticsAvoid benzos except with ETOH withdrawlOrient Patients Provide clocks, calenders, windows, structured activitiesHearing aides, glasses
The End Questions/Comments?