Transcript clinical symptoms

Organic disorders I: delirium
M. Kopeček
Delirium = qualitative disturbances
of consciousness
Patient is alert (vigilant) but his/her
consciousness is clouded, non-clear,
non-lucid.
DSM5 diagnostic criteria
A. Disturbance in attention
B. The disturbance develops over a short period of time (usually
hours to a few days), represents a change from baseline attention
and awareness, and tends to fluctuate in severity during the course
of a day.
C. An additional disturbance in cognition (e.g., memory deficit,
disorientation or perception).
D. The disturbances in Criteria A and C are not better explained by
another preexisting, established, or evolving neurocognitive
disorder and do not occur in the context of a severely reduced level
of arousal, such as coma.
E. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is a direct physiological
consequence of another medical condition, substance
intoxication or withdrawal (i.e., due to a drug of abuse or to a
medication), or exposure to a toxin, or is due to multiple etiologies.
A. disturbance in attention
reduced ability to direct, focus,
sustain, and shift attention and
awareness (reduced orientation
to the environment).
serial 7s
• I will ask you to count by subtracting seven from
100, and then, keep subtracting seven from your
answer until I tell you to stop
93...85...79...72...65
point: 1.…0..…0....1..…1
patology: 2 and more failures
cube copying
“Copy this drawing as accurately as you can, in the space below”.
B. an additional disturbance in
cognition
(e.g., memory deficit, disorientation,
language, visuospatial ability, or
perception)
memory deficit
I will tell you three words that you will have
to remember now and later on. Listen
carefully. When I am through, tell me as
many words as you can remember.
• FACE
• VELVET
• DAISY
clock test
“Draw a clock. Put in all the numbers and
set the time to 10 past 11”.
clock test - evaluation
1 point – all numbers
1 point – correct order and placed in the
approx. quadrants on the clock face
1 point – correct place of the hour hand
1 point – correct place of the minute hand
-------------------------------------------4 points = norm
3 points – abnormal result
clock test
memory disturbaces
• “I read some words to you earlier, which I
asked you to remember. Tell me as many
of those words as you can remember.”
disorientation
• What is the day
i.e. Sunday instead Tuesday
today ?
• Tell me the months? autum
1986
• Tell me year ?
• Where we are ? In kitchen, you have a white coute.
• Why we are here? There are no cookies.
Psychomotor disturbances
(ICD10)
1) fluctuating between hypo and
hyperactivity
2) slowing of reaction time
3) brady or tachylalia
4) prolongation of startle reflex
Disturbances of sleep and sleepwake cycle (ICD10)
1) insomnia, inversion of sleep cycle
2) progression of delirum at night
(SUNDOWN sy)
3) uneasy sleep with horrible dreaming
The disturbance develops over a short period
of time (usually hours to a few days),
represents a change from baseline attention
and awareness, and tends to fluctuate in
severity during the course of a day.
clinical symptoms
psychomotor tempo:
decrease or increase
response to questions:
slow, incoherent
clinical symptoms
disturbances of perceptions:
frequent visual and tactile
hallucinations/illusions
thought disorder:
non-systematic delusions
clinical symptoms
judgement impairment:
1. Will a stone float on water ?
2. Are there fish in the sea ?
3. Does one pound weigh more than two?
4. Can you use a hammer to pound a nail?
clinical symptoms
emotions:
fluctuating – anxiety, fear, sedation,
irritability,euforia, suprise
clinical symptoms
Increased sugestibility:
Pt is able to read from white paper/wall.
clinical symptoms
description: puzzled, confused, perplex, disorganised,
disoriented, agitated
description of behavior:
He is not able to find his room….he urinate into the
corner….she put bed sheet to the toilet ….she
unscrew all stopcock of central heating…she did
not sleep, because she saw shining circles …he
saw bugs in the blanket. We did not see
nothing…
type of delirium
symptoms
hyperactive
agitation, hypervigilance,
hallucinations and
delusions
hypoactive
lethargy, sedation,
latention to response, low
spontaneity, hypomimia
mixed
!!!
mix of above
etiology a ddg.
intracranial
- tumor, inflammations, edema, ischemia, bleeding,
trauma, epi-paroxysmus….
extracranial
- toxic substances, alcohol
- shock (cardial, septic, postsurgery)
- hypo/hyperglykemia
- other metab. disord. (hepatic, renal,….)
clinical subtype
F 05.0 delirium, not superimposed on dementia
F 05.1 delirium, superimposed on dementia
F 1X.03 acute intoxication with delirium
F 10.4 withdrawal with delirium
F10.3 alcohol withdrawal state
at least 3 symptoms after sudden reduction or stop of alcohol
consumption
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tremor of tounge, eyelids, hands
sweating
nausea or vomitus
tachycardia or hypertension
headache
insomnia
malaise or faint
acustic, visual or tactile hallucinations/illusions
F10.3 „predelirant state“ that could be complicated with delirium
F10.40 withdrawal state with delirium without convulsions
F10.41 withdrawal state with delirium with convulsions
assessment
history
physical examination
mental state examination
biochemic assay, ECG
…more
therapy of delirium
1. causal tx
2. symptomatic tx (pain, fever, BP..)
3. tx of agitation
4. transfer to intens. care unit
5. arrangement of environment (clock, light,
informations)
causal tx
infection ……….antibiotics
dehydratation….rehydratations
corections of metab.dist.(pH,glyk., urea..)
intoxication……detoxification, antidots
withdrawal state…clomethiazole
tx of agitation
induce appropriate sedation
•
assure patients safety
•
protection of exhaustion
•
improve cooperation during diagnostic process
delirium tremens……diazepam or clomethiazole
non-alcoholic delirium….antipsychotics
delirium without dementia…haloperidole
delirium superimposed on dementia….tiapridale,
buronile,
risperidone/quetiapine
haloperidol in non-alcoh. delirium
• first
option AP
• without anticholinergic and hypotensive side eff.
• i.v., i.m., p.o. application
• plasma C max. i.v. in 5-20 minut
• plasma C max. p.o. in 4-6 hours
• recommended dosis 1-2 mg/ 2-4 hours
antipsychotics in non-alcoh.
delirium (gerontopopulation)
TIAPRIDE
- night deliria – night dose 100 – 200 mg.
- deliria during a day up to 800-1200 mg
MELPERONE
- night deliria – night dose 25-100 mg
- deliria during a day up to 200-300 mg
2nd generation antipsychotics
RISPERIDONE
- one night dos. 0,5-1 mg
- rarely more than 2 mg per die
OLANZAPINE
- 2,5 – 5 mg in one dosis, rarely 10 mg/die
risk of increased mortality induced by risperidone
and olanzapine (NNH = 83, 10-12 week)
QUETIAPINE
- most safe 2nd generation antipsychotics
benzodiazepines
• first option in alcohol delirium or deliria after BZD
withdrawal
• CAVE !!! induction of paradox excitations
• in case of lack of antipsychotics effects
combination with clonazepame
clomethiazole
• inicialy 2-3 capsules and every 4 h up to
sedation. Max. dosis 16 capsules/d.
• Dont mix with BZD (depression of respiration)
• Cave ! No abrupt withdrawal
alcohol withdrawal state
with delirium
• supplementation of thiamine
• minerals (magnesium and kalium)
• glucose and fluids
• clomethiazole or diazepame
supportive medications
• nootropics to improve cerebral metabolism and
vigility sustainment during a day (i.e. piracetamole)
– hypoactive delirium
• vitamins B a C
delirious patient with non-curable malignancy:
• opiate analgetics
• combos: antipsychotic, BZD and hydromorfine
case of 47-y.o. female
She was anxious and agitated. She wrote
confused e-mails. She did not sleep at night,
crying, say over again and again „I am back
at hotel“.
Montreal Cognitive Assessment
total score 10/30
4th day of Augmentin 1g 1-0-1
total score 22/30
2nd case
40-y.o. mason has been admited to ICU after
surgery for perforation of gastric ulcer. 3rd
postsurgery day was transfer to standard ward –
quite, cooperative. 4th day – fever, sweating, 5th
day shaking hands and nausea, 6th day
tachycardia and insomnia, 7th day – confused,
agitated, with visual hallucinations
What do you do with this patient ?
2nd case - therapy
1. inf 500 ml G5%+B1, B6, C+diazepam+KCl
2. inf. FR+MgSO410%+KCl+diazepam+novalgin
3. infuze FR+diazepam
4. inf. like 1
5. inf. like 2
6. inf. like 3
Vasocardin 50 mg tbl. ½-0- ½
Omeprazol 20 mg tbl. 1-0-1
Epi: Epanutine 1 amp. in 10 ml FS slowly i.v.
vomitus: Torecan 1 amp. i.m.
BP over 150/100: Tensiomine 12,5 mg tbl.