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Lecture outline :
1. Introduction
2. Epidemiology & Predisposing factor
3. Etiology
4. Neuropathology of Delirium
5. Clinical Features & Diagnostic criteria for Delirium
6. Course & Outcome
7. Mini mental examination
8. Physical Examination & Lab. Investigations
9. Treatment
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Delirium is defined by the acute onset of fluctuating cognitive
impairment and a disturbance of consciousness. It is a
medical emergency.
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Delirium by Other Names :
Intensive care unit psychosis, Acute confusional state,
Acute brain failure, Encephalitis, Encephalopathy, Toxic
metabolic state
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Epidemiology
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Predisposing factor
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Etiology
I. Intracranial causes
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I. Intracranial causes
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II. Extracranial causes
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C. Endocrine dysfunction
e.g., Thyroid, Parathyroid, Pancreas, Adrenal
E. Deficiency disorders
e.g., Thiamine, nicotinic acid, B12, folic acid
deficiencies 10
Others
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Neuropathology of Delirium
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Clinical Features
1.Emotional disturbances
2.Psychomotor disturbances
3.Disturbance in consciousness & attention
4.Disorientation
5.Impaired memory
6.Perceptual disturbances
7.Thought disturbances
8.sleep-wake cycle disruption
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1.Emotional disturbances
2.Psychomotor disturbances
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A. Hypoactive
Extreme fatigue & slow to respond
Increased sleep
B. Hyperactive
May become agitated & violent
Remove IV lines, dressing & catheters
Restless & try to get out of bed
sleepless
C. Mixed
Mixture of agitation & hypoactive behaviors that can vary
through out the day 15
3. Disturbances in consciousness & attention
reduced clarity of awareness of the environment
inability to focus, sustain or shift attention
4. Disorientation
Usually disoriented to time, to place, rarely to person
5. Impaired memory
Failure to register events into memory
patients fail test of memory (almost all types of memory)
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6. Perceptual Disturbances
Illusions, Or Hallucinations
7. Thought disturbances
Disorganization of thought process (rambling /
incoherent speech)
Delusions (e.g., persecutory delusion)
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DSM5-Diagnostic Criteria for Delirium
A. A disturbance in attention & awareness
B The disturbance develops over a short period of time, &
tends to fluctuate in severity during the course of a day
C. An additional disturbance in cognition ( memory deficit,
disorientation, language, visuo-spatial ability, or
perception)
D. Criteria A & C are not better explained by another
preexisting, established, or evolving Neurocognitive
disorder (NCD) & do not occur in the context of a severely
reduced level of arousal (coma)
E. There is evidence from the Hx , PE / Lab findings that the
disturbance is a direct physiological consequence of
another medical condition, substance intoxication or
withdrawal , or exposure to a toxin, or is due to multiple
etiologies. 18
Mini-Mental State Examination(MMSE)
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MMSE :
Orientation (score 1 if correct)
Name this hospital, or building? ___ What state are you in? ___
What city are you in now? ___ What country is it? ___
What year is it? ___ What floor of the building are you on? ___
What month is it? ___ What day of the week is it? ___
What is the date today? ___ What season of the year is it? ___
Registration (score 1 for each object correctly repeated)
Name three objects ___
Attention & calculation (sc.=5) Subtraction 7 from 100 in serial fashion to 65 ___
Recall (score 1 for each object recalled) ___
Do you recall the three objects named before? ___
Language tests
Confrontation naming: watch, pen=2 ___
Repetition ”No ifs, ands, or buts”=1 ___
Comprehension: Pick up the paper in your right hand, fold it in half, set in the
floor=3 ___
Read & perform the command “close your eyes”=1 ___
Write any sentence =1. ___
Construction: copy the design (pentagon ) =1 ___
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Evaluation of patient with suspected delirium
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Specify whether (Etiological factor)
Hyperactive
Hypoactive
mixed
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Course
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Prognosis
Full recovery
Progression to stupor & or coma
Progression to chronic brain syndromes (e.g., Amnestic
syndromes)
Development of seizure (e.g., Alcohol withdrawal)
Death
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Differential Diagnosis
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3. Dementia
Insidious onset
Symptoms usually do not fluctuate over the course of a day
No change on level of consciousness (patient is alert)
4. Depression
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Treatment
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1. Identify & treat the underlying cause
History taking
Physical Examination
Lab investigations
Appropriate & immediate treatment of the
medical condition
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2. Environmental & psychosocial interventions
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3. Psychopharmacological treatment
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Erasinus, who lived near the Canal of Bootes, was
seized with fever after supper; passed the night in an
agitated state. During the first day quiet, but in pain at
night. On the second, symptoms all exacerbated; at night
delirious. On the third, was in a painful condition; great
incoherence. On the fourth, in a most uncomfortable state;
had no sound sleep at night, but dreaming and talking;
then all the appearances worse, of a formidable and
alarming character; fear, impatience. On the morning of
the fifth, was composed, and quite coherent, but long
before noon was furiously mad, so that he could not
constrain himself; extremities cold, and somewhat livid;
urine without sediment; died about sunset.
Hipocratus (400 BC)
THANK YOU !
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