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What is the primary characteristic of a disturbance in attention in delirium?
What is the typical duration of the development of a disturbance in delirium?
What is the exclusion criteria for delirium according to DSM-V-TR?
What is required to diagnose delirium according to DSM-V-TR?
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What is the primary cognitive disturbance in delirium?
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What is the primary reason for the decreased ability to recover from insults as people age?
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Which of the following is NOT a common acute symptom of concussion?
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What is the term for the distortion of cellular membranes due to biomechanical forces in traumatic brain injury?
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What is the primary goal of the initial treatment for concussion?
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What is the term for the chronic neurologic consequences of repetitive mild TBI?
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Which of the following is a risk factor for developing Chronic Traumatic Encephalopathy (CTE)?
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What is the primary difference between delirium and Post-Concussion Syndrome?
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What is the primary purpose of the Confusion Assessment Method (CAM)?
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What is the term for the gross pathological feature of Chronic Traumatic Encephalopathy (CTE)?
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What is the term for the histologic feature of Chronic Traumatic Encephalopathy (CTE)?
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What is the primary reason why elderly people may only present with delirium in medical illnesses?
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Which of the following is NOT a metabolic derangement that can cause delirium?
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What is the primary purpose of the EEG in the evaluation of delirium?
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What is the term for the type of traumatic brain injury that occurs after force to the brain?
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What is the primary difference between concussion and Post-Concussion Syndrome?
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What is the term for the long-term neurologic consequences of repetitive mild traumatic brain injury?
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Which of the following is a risk factor for developing Chronic Traumatic Encephalopathy?
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What is the primary goal of the initial treatment for concussion?
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What is the term for the process by which cellular membranes are distorted due to biomechanical forces in traumatic brain injury?
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What is the primary purpose of the Confusion Assessment Method (CAM)?
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Which of the following is a key feature of delirium, according to the DSM-V-TR?
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What is the primary reason for excluding another preexisting, evolving, or established neurocognitive disorder in the diagnosis of delirium?
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Which of the following is NOT a required criterion for diagnosing delirium, according to the DSM-V-TR?
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What is the primary role of evidence from the history, physical examination, or laboratory findings in the diagnosis of delirium?
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Which of the following is a characteristic of the cognitive disturbance in delirium, according to the DSM-V-TR?
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Study Notes
Delirium
- Disturbance in attention and reduced awareness of the environment, developing over a short period of time (hours to days) with fluctuations during the day.
- Additional disturbance in cognition, including memory deficit, disorientation, language, visuospatial ability, or perception.
- Not explained by another preexisting, evolving, or established neurocognitive disorder, and not occurring in the context of a severely reduced level of arousal, such as coma.
- Evidence from history, physical examination, or laboratory findings suggests the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.
Clinical Presentation of Delirium
- Altered cognition
- Altered consciousness
- Elderly individuals may only present with delirium in the context of a medical illness
- Elderly individuals may have a prodromal phase
- Other findings include psychomotor agitation, irritability, and anxiety
Etiology of Delirium
- Result of some sort of insult, with decreased ability to recover from damages as we age
- Causes include:
- Drugs and toxins
- Infections (sepsis, systemic infections, fever-related delirium)
- Metabolic derangements (electrolyte disturbances, endocrine disturbances, hyperglycemia, hypoglycemia, hypoxemia)
- Brain disorders
- Systemic organ failure
- Physical barriers
Epidemiology of Delirium
- Approximately 30% of elderly hospitalized patients experience delirium
- Confusion Assessment Method (CAM) is used for delirium detection
- CAM-ICU is used for patients in intensive care units
Evaluation and Diagnosis of Delirium
- Exam findings: non-focal, myoclonus, asterixis
- Ancillary testing:
- EEG with diffuse slowing to exclude seizures
- LP with meningitis
- MRI with acute infarcts/leptomeningeal disease
- CT is less likely to pick up an acute process and is not done routinely (unless papilledema, coma, or pre-LP)
Concussion
- Definition: signs and symptoms occurring after force to the brain, a type of traumatic brain injury
- Epidemiology:
- Most common sports-related TBI
- Highest rates in pediatric age ranges
- Males sustain more concussions than females
- High-risk sports
Pathophysiology of Concussion
- Biomechanical forces distort cellular membranes
- In neurons, this results in transient membrane defects (mechanoporation) and ionic flux
Clinical Presentation of Concussion
- The most common acute symptoms include:
- Headache
- Nausea
- Dizziness
- Confusion
- Memory impairment
- Loss of consciousness is not a requirement for concussion diagnosis
- Less than 10% of diagnosed concussions involve a loss of consciousness
- Some anterograde or retrograde amnesia is more common
Diagnostic Evaluation and Treatment of Concussion
- Evaluation in the field: ABCs, seizure, prolonged loss of consciousness, evidence of cervical spine injury
- Sports Concussion Assessment Tool 3 (SCAT3)
- Treatment: brain rest, remove from participation, direct observation, and arrange follow-up with comprehensive neuro exam within 24 hours
- Return to play: graduated exertion
Post-Concussion Syndrome
- Persistent neurobehavioral impairments after concussion
- Chronic Post-concussion Syndrome: symptoms present >1 year after injury
- Symptoms include:
- Headache
- Dizziness
- Memory impairment
- Irritability
- Attention/concentration problems
- Depression
- Anxiety
Chronic Traumatic Encephalopathy (CTE)
- Long-term neurologic consequences of repetitive mild TBI
- Dementia pugilistica
- Exact frequency unknown
- Risk factors:
- Exposure to contact/collision sports
- Duration of exposure to sport
- Years since retirement from sport
- Increasing age
- Multiple concussions
- Multiple subconcussive impacts
- Apolipoprotein E (APOE) *E4 genotype
- Pathology and clinical presentation:
- Gross pathological features: diffuse brain atrophy, ventricular dilatation, cavum septum pellucidum with or without fenestrations, cerebellar scarring, and depigmentation/degeneration of the substantia nigra
- Histologic features: neuritic threads and neurofibrillary tangles in various locations
- CTE can present clinically with behavioral, cognitive, and motor symptomatology
Delirium
- Disturbance in attention and reduced awareness of the environment, developing over a short period of time (hours to days) with fluctuations during the day.
- Additional disturbance in cognition, including memory deficit, disorientation, language, visuospatial ability, or perception.
- Not explained by another preexisting, evolving, or established neurocognitive disorder, and not occurring in the context of a severely reduced level of arousal, such as coma.
- Evidence from history, physical examination, or laboratory findings suggests the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.
Clinical Presentation of Delirium
- Altered cognition
- Altered consciousness
- Elderly individuals may only present with delirium in the context of a medical illness
- Elderly individuals may have a prodromal phase
- Other findings include psychomotor agitation, irritability, and anxiety
Etiology of Delirium
- Result of some sort of insult, with decreased ability to recover from damages as we age
- Causes include:
- Drugs and toxins
- Infections (sepsis, systemic infections, fever-related delirium)
- Metabolic derangements (electrolyte disturbances, endocrine disturbances, hyperglycemia, hypoglycemia, hypoxemia)
- Brain disorders
- Systemic organ failure
- Physical barriers
Epidemiology of Delirium
- Approximately 30% of elderly hospitalized patients experience delirium
- Confusion Assessment Method (CAM) is used for delirium detection
- CAM-ICU is used for patients in intensive care units
Evaluation and Diagnosis of Delirium
- Exam findings: non-focal, myoclonus, asterixis
- Ancillary testing:
- EEG with diffuse slowing to exclude seizures
- LP with meningitis
- MRI with acute infarcts/leptomeningeal disease
- CT is less likely to pick up an acute process and is not done routinely (unless papilledema, coma, or pre-LP)
Concussion
- Definition: signs and symptoms occurring after force to the brain, a type of traumatic brain injury
- Epidemiology:
- Most common sports-related TBI
- Highest rates in pediatric age ranges
- Males sustain more concussions than females
- High-risk sports
Pathophysiology of Concussion
- Biomechanical forces distort cellular membranes
- In neurons, this results in transient membrane defects (mechanoporation) and ionic flux
Clinical Presentation of Concussion
- The most common acute symptoms include:
- Headache
- Nausea
- Dizziness
- Confusion
- Memory impairment
- Loss of consciousness is not a requirement for concussion diagnosis
- Less than 10% of diagnosed concussions involve a loss of consciousness
- Some anterograde or retrograde amnesia is more common
Diagnostic Evaluation and Treatment of Concussion
- Evaluation in the field: ABCs, seizure, prolonged loss of consciousness, evidence of cervical spine injury
- Sports Concussion Assessment Tool 3 (SCAT3)
- Treatment: brain rest, remove from participation, direct observation, and arrange follow-up with comprehensive neuro exam within 24 hours
- Return to play: graduated exertion
Post-Concussion Syndrome
- Persistent neurobehavioral impairments after concussion
- Chronic Post-concussion Syndrome: symptoms present >1 year after injury
- Symptoms include:
- Headache
- Dizziness
- Memory impairment
- Irritability
- Attention/concentration problems
- Depression
- Anxiety
Chronic Traumatic Encephalopathy (CTE)
- Long-term neurologic consequences of repetitive mild TBI
- Dementia pugilistica
- Exact frequency unknown
- Risk factors:
- Exposure to contact/collision sports
- Duration of exposure to sport
- Years since retirement from sport
- Increasing age
- Multiple concussions
- Multiple subconcussive impacts
- Apolipoprotein E (APOE) *E4 genotype
- Pathology and clinical presentation:
- Gross pathological features: diffuse brain atrophy, ventricular dilatation, cavum septum pellucidum with or without fenestrations, cerebellar scarring, and depigmentation/degeneration of the substantia nigra
- Histologic features: neuritic threads and neurofibrillary tangles in various locations
- CTE can present clinically with behavioral, cognitive, and motor symptomatology
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Description
This quiz covers the clinical presentation, other findings, etiology, and causes of delirium in elderly patients, including altered cognition, psychomotor agitation, and infections.
