Memory Joggers: Delerium
DELIRIUM = restlessness, agitation, clouding of consciousness, bizarre behavior, hallucinations, delusions and illusions
Delirium - a decreased clarity of awareness of the environment
Dementia - state of irreversible loss of memory and a global cognitive deficit
_________dementia is associated with a normal level of consciousness
Drugs, Dehydration
Electrolyte imbalances,
___Environmental changes—location,
___Extremes of temperature
Liver disease - encephalopathy,
___Lungs - hypoxia
Infection -esp UTI and pneumonia,
___Immune system dysfunction,
___Intracranial lesions
Retention - urinary or fecal
Ischemia - cerebral or cardiac,
___ Intoxication,Intestinal obstruction
Uremia
| . |
Delirum |
Dementia |
Acute Functional Psychosis |
| Onset |
Sudden |
Insidius |
Sudden |
| Course over 24 hrs |
Fluctualting with nocturnal exacerbation |
Stable |
Stable |
| Consciousness |
Reduced |
Clear |
Clear |
| Attention |
Globally disordered |
Normal
except severe |
May be disordered |
| Cognition |
Globally disordered |
Globally impaired |
Selective Impairment |
| Hallucinations |
Usually visual or visual and auditory |
Often absent |
Predominant auditory |
| Delusions |
Fleeting, poorly systematized |
Often absent |
Sustained systematized |
| Orientation |
Usually impaired |
Often impaired |
May be impaired |
| Psychomotor activity |
Variable |
Often normal |
Varies |
| Speech |
Often incoherent |
Difficulty finding words |
Normal,slow, or rapid |
| Involuntary movements |
Often asterixis or coarse tremor |
Often absent |
Usually absent |
| Physical illness or drug toxicity |
One or both are present |
Often absent |
Usually absent |
Causes of delirium
Central Nervous System
Dementia - usually associated with
a normal level of consciousness
Alzheimer’s disease
Multi-infarct dementia
Parkinson’s disease
Normal pressure hydrocephalus
Malignancy—primary CNS tumor,
CNS metastasis, paraneoplastic
syndrome
Head trauma—subdural and epidural
hematoma, concussion
Post-ictal state
Stroke
Hypertensive encephalopathy
Wernicke’s encephalopathy—
thiamine deficiency
B12 deficiency
Carbon monoxide poisoning
Systemic
Drugs
Alcohol withdrawal
Narcotic and sedative drug excess
or withdrawal
Analgesics—NSAIDs, salicylates
Anti-hypertensives —
centrally acting -
methyldopa,clonidine
beta blockers
postganglionic sympathetic
blockers—reserpine
Psychotropic medications—
tricyclic antidepressants, lithium,
phenothiazines, MAO inhibitors,
benzodiazepines
Corticosteroids
Hypoglycemics
Lithium
Sympathomimetics—amphetamines,
ephedrine, methylxanthines,
phenylpropanolamine, phenylephrine
Miscellaneous—cimetidine
Anticholinergics—
antihistamines (diphenhydramine),
Anti-Parkinsonisms medications
Antispasmodics, cycloplegics
Digoxin
Anti-epileptic drugs
Organ Failure
Respiratory failure-
hypoxia, CO2 retention, fat
embolism syndrome,
pulmonary embolism
Renal Failure
Liver failure
Myocardial disease
Infarction
Arrhythmia
Congestive heart failure
Hypertensive encephalopathy
Metabolic
Dehydration
Hypothermia
Hyperthermia
Hyperglycemia
Hypoglycemia
Hypernatremia
Hyponatremia
Hypercalcemia
Endocrine
Hyperthyroidism
Hypothyroidism
Hyperadrenocorticism
Hypoadrenocorticism
Infection
Meningitis
Encephalitis
Brain abscess
Lyme disease
Cerebral vasculitis—
SLE, polyarteritis nodosa
Sepsis
Psychiatric disorders
Mania
Depression
Schizophrenia
Miscellaneous
Urinary retention
Fecal retention
Intestinal obstruction
Pertinent History
?trauma
?drugs—
prescription, illicit, and over the
counter ->any drugs usual dose
can cause confusion in the elderly
?alcohol
Physical exam
Airway—
receiving 02 greater than
FiO2 > 28—think hypercarbia
Respiratory
Cyanosis--?hypoxia
Barrel chest--?COPD with hypoxia or
hypercarbia
Bibasilar crackles--?CHF with hypoxia
Vital signs
Autonomic dysfunction—
tachycardia--
?sepsis, delirium tremens
?hyperthyroidism, ?hypoglycemia
bradycardia,
flushing,
Pallor,
Hypertension,
Hypotension--?shock,
?drug overdose,
?adrenal insufficiency,
?hyponatremia
Impairment of pupillary reaction
Impairment of sweating function
Fever—not always manifested in elderly
?infection, delirium tremens, cerebral
vasculitis,fat embolism syndrome
CVS—elevated JVP, S3,
pitting edema—?CHF
Abd—
costovertebral angle tenderness-
?pyelonephritis
Guarding, rebound tenderness-
?intra-abdominal infection
Shifting dullnes, dilated
superficial veins, caput medusa
?liver failure
Neuro—
argyll robertson pupils—
accommodate but do not react to
light--?syphillis
Cranial nerve palsies—lyme disease
Asterixis, constructional apraxia-
?liver failure
Skin—
axillary fold, neck, upper chest
petechiae--?fat embolism
Nonspecific
New onset of asterixis,
tremor or seizure
Nuchal rigidity--?meningitis
Papilledema—
?hypertensive encephalopathy,
intracranial mass
Pupil size and symmetry
Dilated—sympathetic overflow-
?delirium tremens
Pinpoint--?narcotic excess or
recent eyedrops
Conjunctival and fundal petechiae-
?fat embolism syndrome
Lacerated tongue or cheek-
?post-ictal
Goiter-
?hyperthyroidism, ?hypothyroidism
Palpate the skull for fractures,
hematomas, and lacerations
?subdural or epidural hematoma,
concussion
Tympanic Membrane—
hemotympanum or blood in the
ear canal
?basal skull fracture
Asymmetry of pupils, visual
fields, eye movement, limbs, tone,
Reflexes, or plantars-
?structural brain disease
Laboratory
Blood glucose
Urea
Creatinine
Liver function test
Sodium
Calcium
Magnesium
Albumin
Hemoglobin
MCV
RBC morphology—
anemia with oval macrocytes—
B12 or folate deficiency
WBC and differential
ABG—hypoxia or CO2 retention
T4, TSH
ANA
RF
ESR
C3, C4
Drug levels—
digoxin, lithium, aspirin,
anti-epileptic drugs
Urinalysis
Blood cultures
?Serum ammonia level
Urine cultures
Illicit drug screen
Alcohol level
Further tests
CXR
EKG
EEG CT or MRI esp if trauma or
focal/abnormal neurologic exam
LP if meningitis/encephalitis is
suspected esp if patient has
potential for immunosuppression
References:
On Call principles, Gilles M.D.
1989 Saunders p 44 - 53
Saunders Manual of Medical Practice
1996 Rakel p 1025-1027
Primary Care Desk Reference
1996 Delirium
Algorithmic Diagnosis of Symptoms
and Signs 1995 p. 123-124
Emergency Medicine: An Approach to
Clinical Problem Solving 1991
pp 807-829
Has very nice algorithm on
comatose and delirious patient
evaluation
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