[ Pobierz całość w formacie PDF ]
trauma. Ask about cardiovascular disease, liver
disease (hepatic encephalopathy), and renal
disease (uremia).
Medications: Obtain details of medications, with
dosages and duration of treatment. Ask about
over-the-counter medication and alternative
treatments. Toxic levels of anticholinergics,
anticonvulsants, antipsychotics, antihypertensives,
steroids, lithium, and sedatives can cause delir
ium.
Mental Status Exam
General appearance: Inattentive, limited eye
contact, confused.
Speech: Normal rate, rhythm, and volume.
Mood: Angry, afraid.
Affect: Dysphoric, irritable, and labile.
Thought process: Tangential, incoherent, or
irrelevant speech.
Thought content: Paranoid delusions without
systematized content.
Perceptual: Auditory and visual hallucinations are
most common in delirium.
Suicidality: Varies according to the presence of
psychosis and affective symptoms.
Homicidality: May occur in association with
paranoia.
Sensorium/cognition: Not alert, disoriented, with
fluctuating level of consciousness. Impaired
memory and concentration, poor attention and
limited problem-solving abilities.
Impulse control: Limited. Patients may be ag
gressive with difficulty controlling anger.
Judgment: Impaired. Patients may be inappropri
ate and disinhibited.
Insight: Fair. Patients realize the nature of their
symptoms.
Reliability: Limited. Attention and thinking are
typically too impaired to give a reliable history.
Laboratory data: Complete blood count, chemis
try, thyroid function tests, RPR, HIV testing,
urinalysis, toxicology screen, serum medication
levels, blood and urine cultures if indicated, vita
min B12, thiamine, and folate levels, and lumbar
puncture with CSF examination if indicated.
Diagnostic testing: Electroencephalography,
chest x-ray, computed tomography, and Delirium
Rating Scale.
Diagnosis: Axis I: Delirium due to a general
medical condition, substance intoxication delirium,
substance withdrawal delirium, delirium due to
multiple etiologies, and delirium not otherwise
specified
Differential Diagnosis
Psychiatric: Dementia, substance intoxication or
withdrawal, depression, schizophrenia, brief
psychotic disorder, mania, and dissociative disor
ders.
Medical: Epilepsy, head trauma, infection, medi
cation toxicity (eg, anticholinergics,
anticonvulsants, antipsychotics, antihypertensives,
sedatives, lithium, steroids), heavy metal poison
ing, endocrine dysfunction, hepatic
encephalopathy, uremic encephalopathy, carbon
dioxide toxicity, hypoxia, cardiac failure, vitamin
deficiencies (eg, thiamine, B12, folate), and
electrolyte imbalance.
Table 6. Delirium vs. Dementia
Delirium Dementia
Clouding of conscious No changes in conscious
ness ness
Significant attention Less attention deficit
deficit
Abrupt onset (hours to Gradual onset (weeks to
days) years)
Transient duration Chronic duration
Fluctuating symptom Gradual worsening of
severity symptoms
Delirium - Discussion
I. Epidemiology
A. Up to one-third of patients on surgical wards,
medical wards, or intensive care units expe
rience delirium over the course of their
hospital admission.
B. Patients with underlying dementia and the
elderly are at the greatest risk of developing
delirium. Other risk factors include preexist
ing brain damage, a history of delirium,
alcohol dependence, recent surgery, and
malnutrition.
C. The presence of delirium increases mortal
ity.
II. Etiology
A. The most common causes of delirium are
central nervous system disease, systemic
disease (eg, cardiac failure), and substance
or medication intoxication or withdrawal.
B. Causes of postoperative delirium include
pain, electrolyte imbalance, infection, fever,
and blood loss.
C. Acetylcholine has been hypothesized to be
the major neurotransmitter involved in delir
ium, and the reticular formation may be the
primary neuroanatomical area.
III.Clinical evaluation
A. The hallmark of delirium is clouding of
consciousness accompanied by a reduced
ability to sustain attention. Patients typically
have impaired cognitive function with mem
ory deficit and disorientation. Perceptual and
psychomotor disturbances also occur.
B. Physical signs of delirium may include
flushing, pallor, sweating, tachycardia, nau
sea, and vomiting.
C. Neurological signs of delirium may include
dysphasia, tremor, asterixis, ataxia, and
incontinence. Symptoms tend to develop
abruptly over several hours and may last
days to weeks. Symptom severity may
fluctuate over the course of the day, ranging
from severe impairment and disorganization
to periods of lucidity.
D. Delirium should always be suspected in
patients on medical or surgical wards with
psychiatric symptoms that are new or abrupt
in onset.
IV. Treatment
A. Agitated behavior is the most common
reason for admission or consultation in
patients with delirium. Delirium requires
treatment of the underlying etiology. Medi
cating symptoms should usually be avoided.
In anticholinergic toxicity, physostigmine
may be used in repeated doses.
B. High-potency antipsychotics with low
anticholinergic side effects (eg, haloperidol)
are used for psychotic symptoms.
C. Patients must be carefully monitored to
avoid potential harm from falls, agitated
behavior, or other accidents. Maintaining an
environment that minimizes stimulation may
reduce agitation.
References, see page 92.
Suicidal Ideation - History
Taking
History of present illness: The interview should
begin with questions about current symptoms,
duration, and date of onset. Ask about recent life
changes, interpersonal stress, marital conflict,
illness in the family, or legal problems. Assess
suicide potential by addressing intent, plans,
means, and perceived consequences. Distinguish
between passive and active suicidal ideation in
assessing intent by asking about specific plans,
the ability to resist suicidal impulses, and what
factors influence the degree of determination,
such as, children, spouse, or work.
Assess the lethality of the plan, and ask about any [ Pobierz całość w formacie PDF ]
zanotowane.pl doc.pisz.pl pdf.pisz.pl ocenkijessi.opx.pl
trauma. Ask about cardiovascular disease, liver
disease (hepatic encephalopathy), and renal
disease (uremia).
Medications: Obtain details of medications, with
dosages and duration of treatment. Ask about
over-the-counter medication and alternative
treatments. Toxic levels of anticholinergics,
anticonvulsants, antipsychotics, antihypertensives,
steroids, lithium, and sedatives can cause delir
ium.
Mental Status Exam
General appearance: Inattentive, limited eye
contact, confused.
Speech: Normal rate, rhythm, and volume.
Mood: Angry, afraid.
Affect: Dysphoric, irritable, and labile.
Thought process: Tangential, incoherent, or
irrelevant speech.
Thought content: Paranoid delusions without
systematized content.
Perceptual: Auditory and visual hallucinations are
most common in delirium.
Suicidality: Varies according to the presence of
psychosis and affective symptoms.
Homicidality: May occur in association with
paranoia.
Sensorium/cognition: Not alert, disoriented, with
fluctuating level of consciousness. Impaired
memory and concentration, poor attention and
limited problem-solving abilities.
Impulse control: Limited. Patients may be ag
gressive with difficulty controlling anger.
Judgment: Impaired. Patients may be inappropri
ate and disinhibited.
Insight: Fair. Patients realize the nature of their
symptoms.
Reliability: Limited. Attention and thinking are
typically too impaired to give a reliable history.
Laboratory data: Complete blood count, chemis
try, thyroid function tests, RPR, HIV testing,
urinalysis, toxicology screen, serum medication
levels, blood and urine cultures if indicated, vita
min B12, thiamine, and folate levels, and lumbar
puncture with CSF examination if indicated.
Diagnostic testing: Electroencephalography,
chest x-ray, computed tomography, and Delirium
Rating Scale.
Diagnosis: Axis I: Delirium due to a general
medical condition, substance intoxication delirium,
substance withdrawal delirium, delirium due to
multiple etiologies, and delirium not otherwise
specified
Differential Diagnosis
Psychiatric: Dementia, substance intoxication or
withdrawal, depression, schizophrenia, brief
psychotic disorder, mania, and dissociative disor
ders.
Medical: Epilepsy, head trauma, infection, medi
cation toxicity (eg, anticholinergics,
anticonvulsants, antipsychotics, antihypertensives,
sedatives, lithium, steroids), heavy metal poison
ing, endocrine dysfunction, hepatic
encephalopathy, uremic encephalopathy, carbon
dioxide toxicity, hypoxia, cardiac failure, vitamin
deficiencies (eg, thiamine, B12, folate), and
electrolyte imbalance.
Table 6. Delirium vs. Dementia
Delirium Dementia
Clouding of conscious No changes in conscious
ness ness
Significant attention Less attention deficit
deficit
Abrupt onset (hours to Gradual onset (weeks to
days) years)
Transient duration Chronic duration
Fluctuating symptom Gradual worsening of
severity symptoms
Delirium - Discussion
I. Epidemiology
A. Up to one-third of patients on surgical wards,
medical wards, or intensive care units expe
rience delirium over the course of their
hospital admission.
B. Patients with underlying dementia and the
elderly are at the greatest risk of developing
delirium. Other risk factors include preexist
ing brain damage, a history of delirium,
alcohol dependence, recent surgery, and
malnutrition.
C. The presence of delirium increases mortal
ity.
II. Etiology
A. The most common causes of delirium are
central nervous system disease, systemic
disease (eg, cardiac failure), and substance
or medication intoxication or withdrawal.
B. Causes of postoperative delirium include
pain, electrolyte imbalance, infection, fever,
and blood loss.
C. Acetylcholine has been hypothesized to be
the major neurotransmitter involved in delir
ium, and the reticular formation may be the
primary neuroanatomical area.
III.Clinical evaluation
A. The hallmark of delirium is clouding of
consciousness accompanied by a reduced
ability to sustain attention. Patients typically
have impaired cognitive function with mem
ory deficit and disorientation. Perceptual and
psychomotor disturbances also occur.
B. Physical signs of delirium may include
flushing, pallor, sweating, tachycardia, nau
sea, and vomiting.
C. Neurological signs of delirium may include
dysphasia, tremor, asterixis, ataxia, and
incontinence. Symptoms tend to develop
abruptly over several hours and may last
days to weeks. Symptom severity may
fluctuate over the course of the day, ranging
from severe impairment and disorganization
to periods of lucidity.
D. Delirium should always be suspected in
patients on medical or surgical wards with
psychiatric symptoms that are new or abrupt
in onset.
IV. Treatment
A. Agitated behavior is the most common
reason for admission or consultation in
patients with delirium. Delirium requires
treatment of the underlying etiology. Medi
cating symptoms should usually be avoided.
In anticholinergic toxicity, physostigmine
may be used in repeated doses.
B. High-potency antipsychotics with low
anticholinergic side effects (eg, haloperidol)
are used for psychotic symptoms.
C. Patients must be carefully monitored to
avoid potential harm from falls, agitated
behavior, or other accidents. Maintaining an
environment that minimizes stimulation may
reduce agitation.
References, see page 92.
Suicidal Ideation - History
Taking
History of present illness: The interview should
begin with questions about current symptoms,
duration, and date of onset. Ask about recent life
changes, interpersonal stress, marital conflict,
illness in the family, or legal problems. Assess
suicide potential by addressing intent, plans,
means, and perceived consequences. Distinguish
between passive and active suicidal ideation in
assessing intent by asking about specific plans,
the ability to resist suicidal impulses, and what
factors influence the degree of determination,
such as, children, spouse, or work.
Assess the lethality of the plan, and ask about any [ Pobierz całość w formacie PDF ]