Tutorial #35: Delirium

Question 1

What is the definition of sepsis?

Answer 1

Life-threatening organ dyfunction caused by a dysregulated host response to infection.

Organ dysfunction can be measured using tools such as SOFA/qSOFA

Question 2

What is the definition of septic shock (x3)?

Answer 2

Persistent hypotension despite adequate fluid resuscitation

+

initiation vasopressors to maintain MAP >= 65 mmHg

+

Lactate >= 2 mmol/L in the absence of hypovolemia

Question 3

Which medications have a significant anticholinergic side effect? (x3)

Answer 3

1. antihistamines
2. tricyclic antidepressants
3. antipsychotics

There are a lot of meds w/ antichol effects, these are just three common ones

Question 4

What are the symptoms of anticholinergic toxicity (x6)?

Answer 4

Red as a beet (flushing)
Dry as a bone (anhidrosis)
Hot as a hare (hyperthermia)
Blind as a bat (blurry vision)
Mad as a hatter (agitated delirium)
Full as a flask (urinary retention)

all similar to sympathomimetic EXCEPT dry skin

Question 5

›

In terms of onset of symptoms how can you differentiate between delirium vs dementia?

Answer 5

delirium - ACUTE/fluctuating decline in cognitive function

dementia - progressive, insidious decline over months to years.

Question 6

In terms of attention how can you differentiate between delirium vs dementia?

Answer 6

delirium - attention and orientation are impaired

dementia - attention and orientation are generally preserved

Question 7

In terms of level of consciousness how can you differentiate between delirium vs dementia?

Answer 7

Delirium - fluctuating, sometimes reduced

Dementia - Normal

Question 8

What is the Confusion Assessment Method (CAM) for delirium?

Answer 8

A patient is most likely delirious if:

The patient has both:
a. The mental status change is of acute onset and fluctuating course AND
b. There is inattention

and at least 1 of:

c. presence of disorganized thinking OR
d. There is an altered level of consciousness

Question 9

What is the treatment for delirium (x2)?

Answer 9

Treat underlying cause, and then supportive measures.

Question 10

What are 6 causes of reversible dementia

Answer 10

1. CNS infections
2. hypothyroidism
3. Vitamin B12 deficiency
4. CNS masses (neoplasms, subdural hematomas)
5. Normal-pressure hydrocephalus
6. Medications

The testing threshold for these etiologies of dementia is very low. Consider ruling these out in your workup of a patient who is presenting with cognitive decline!

Question 11

What are DIMS causes for delirium (i.e. name the categories)

Answer 11

Drugs
Infection/inflammation
Metabolic (largest category)
Structural (“brain” problem)

Question 12

What are the “D” causes of delirium in DIMS?

Answer 12

Drugs (therapeutic, intoxication or withdrawal): Prescription medications, illicit drugs, pesticides, solvents, environmental/heavy metal exposure, post-anesthesia, alcohol (intox or withdrawal), sedative hypnotic (intox or withdrawal)

Question 13

What are the “I” causes of delirium in DIMS?

Answer 13

Infection/inflammation: Sepsis, CNS infections (meningitis/encephalitis), vasculitis, syphilis, rheumatological (i.e. lupus cerebritis), post-operative

Question 14

What are the “M” causes of delirium in DIMS?

Answer 14

Metabolic (largest category): electrolyte disturbances, organ failure (cardiac, hepatic, renal), endocrinopathies (thyroid, glucose), vitamin deficiencies (B12, thiamine)

Question 15

What are the “S” causes of delirium in DIMS?

Answer 15

Structural (“brain” problem): trauma, stroke, ICH, hydrocephalus, seizures, tumors, hypertensive encephalopathy

Question 16

What does a DIMS delirium workup look like?

Answer 16

• Drugs: can be identified history, toxidrome or patient’s medication list
• Infection: icareful head-to-toe exam, identify source (urine, imaging), gather cultures and start empiric antibiotics
• Metabolic: order appropriate lab studies including TSH where appropriate
• Structural: consider CT brain

Question 17

What is a Choosing Wisely statement for the workup of delirium in hospitalized patients?

Answer 17

Don’t routinely obtain head computed tomography (CT) scans, in hospitalized patients with delirium in the absence of risk factors.

Delirium is a common problem among hospitalized patients. In the absence of risk factors for intracranial causes of delirium (such as recent head trauma or fall, new focal neurological findings, and sudden or unexplained prolonged decreased level of consciousness), routine head CT scans are of low diagnostic yield. Guidelines suggest a step-wise approach to the management of new delirium in hospitalized patients and consideration of head CT only in patients with select risk factors.

Question 18

What are positive/negative predictors for sepsis?

Answer 18

+ve Predictors
↑WBC, confusion, tachycardia, fever, source of infection found on history or exam.

-ve Predictors
No confusion, no organ dysfunction, afebrile, normal WBC, normal vital signs

Question 19

What are 3 broad steps to the management of sepsis?

Answer 19

The treatment of sepsis can be complicated, but the basics include:
* Resuscitation including fluids, vasopressors and airway management as needed
* Early initiation of appropriate broad-spectrum antibiotics
* Adequate source control (the diagnostic workup is to address this last point)

in short, resus + abx + source ctrl

Question 20

What is a common endocrine cause of reversible dementia?

Answer 20

Hypothyroidism

Question 21

What is a common vitamin deficiency that can cause reversible dementia?

Answer 21

B12 deficiency

Question 22

If you have a patient with delirium, and suspect a drug cause, what is next step?

Answer 22

Identify via hx, toxidrome, or pt med list

Question 23

If you have a patient with delirium, and suspect a infection cause, what is next step (x3)?

Answer 23

Identify source, cultures, abx

Question 24

If you have a patient with delirium and suspect a metabolic cause, what is next step?

Answer 24

Order appropriate labs (i.e. TSH, etc.)

Question 25

If you have a patient with delirium and suspect a strutural cause, what is the next step?

Answer 25

CT brain

Question 26

What is the rule out test for sepsis?

Answer 26

NONE (trick Q) Sepsis is a clinical diagnosis | per reading 50% of sepsis pt will have -ve culture

Question 27

What is the typical pattern of vital sign changes in sepsis (i.e. BP, temp, RR, and HR)?

Answer 27

Hypotension Fever Tachypnea Tachycardia (decreased BP triggers increase in HR to comprensate)

Question 28

Patients with anticholinergic toxidrome present with sweaty skin, true or false?

Answer 28

False (dry as a bone) | Most important one to know since it diff from sympathomimetic agents

Question 29

In a patient with anticholinergic toxidrome, if you suspect rhabdo, what two tests should be ordered (assume you have already ordered lytes)?

Answer 29

CK Renal tests (i.e. Cr, BUN, etc.)

Question 30

Is delirium an end diagnosis?

Answer 30

NO Seconadry to another process, but you might not identify cause in all cases

Question 31

What is the most common cause of dementia?

Answer 31

Alzheimers Dz | 67% of cases per reading

Question 32

What is the rule out test for AD?

Answer 32

Normal MMSE (w/ no other pathology)

Question 33

What is the non-pharm treatment/mgmt of AD (x5)?

Answer 33

1) Couselling/Education 2) Safety measures 3) Behavior changes (and preparation for them) 4) Depression treatment (50% cases are comorbid) 5) Caregiver support (support groups, etc.)

Question 34

What are the 5 steps of calling a consult?

Answer 34

1) Greeting 2) Who you are/what service 3) Reason for consult 4) Describe case 5) Ask if anything else they would like done, say thank you