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Delirium Due to Multiple Etiologies

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by

Maureen Moreau

on 21 May 2014

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Transcript of Delirium Due to Multiple Etiologies

DSM4 - DSM5
DELIRIUM DUE TO MULTIPLE ETIOLOGIES (SUBSTANCE USE AND GENERAL MEDICAL
CONDITION)

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San Francisco
Budapest
Important
Details
(cc) photo by Metro Centric on Flickr
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Stockholm
(cc) photo by Metro Centric on Flickr
complicated by anticholinergic meds imprimamine (antidepressant) & haoloperidol (antipsychotic)
Assets
map
details
doodles
notes
outlook
photo frame
SYMPTOMS
Etiology
Subdural Hematoma (biological medical condition )
Fall from her bed
Complicated & amplified by medications
Imipramine for depression
Haloperidol for psychotic symptoms
Symptoms
Subdural Hematoma
Diagnosed by CT scan of the brain
Blood haemorrhage between the dura mater and arachnoid layers of the skull (acute & chronic)
Associated with Brain injury/trauma
Chronic (slower progression) causes pressure on the brain and may not be evident until symptoms appear
Chronic Subdural hematoma are common in the elderly
Initial - confused & disoriented, wandering neighbourhood
Secondary - (with meds - imipramine for depression & haloperidol for psychotic symptoms) - more confused & disoriented, psychotic thoughts (being poisoned), verbally & physically abusive
Discontinuation of meds (antidepressant & antipsychotic) she returned to initial state of confusion & disorientation
SYMPTOMS
Differential Diagnosis
Ruled out substance-related etiology (patient returned to confused & disoriented state after meds stopped)
Ruled out Dementia (patient was in good health prior to husband going to hospital - Dementia has a gradual onset not acute like Delirium and confusion and disorientation are not evident in early stages of Dementia.
Ruled out depression and psychosis as symptoms did not improve with the medication.
The phrase "
general medical condition
" is replaced in DSM-5 with "
another

medical condition
" where relevant across all disorders.
DSM-4
- Delirium, Dementia, Amnestic, and Other Cognitive Disorders (found on Axis 1 of the Multiaxial system)

DSM-5
- Renamed - Neurocognitive Disorders (no Multiaxial system)
- Addition of '
Mild Neurocognitive Disorder
'
-Except for Delirium, the first step in diagnosis will be to differentiate between normal neurocognitive function, mild neurocognitive disorder (mild NCD) and major neurocognitive disorder (major NCD or Dementia).
DSM-5 pushes the diagnosis and treatment upstream in the disease process of Neurocognitive Disorders.
However, a specific biological marker still remains unknown. Research continues.
Criteria for Delirium have been updated and clarified on the basis of currently available evidence
IMPLICATIONS FOR MRS. T & HER FAMILY

Subdural Hematoma can reoccur-watch for symptoms/changes in behaviour
medical followup (bring family member)
monitor future drug use carefully (assess side effects with doctor/psychiatrist/pharmacist)
have an Occupational Therapist assess home for safety to prevent falls (high incidence in elderly/bed rail, Lifeline
stimulate the mind; puzzles, games, activities, socializing, to decrease onset of other cognitive disorders (dementia)
Delirium - prognosis
Chronic type - Fair
Acute - Poor

Rapid diagnosis & treatment is required for Delirium


Delirium - Axis 1 (Clinical Disorders)
Subdural Hematoma - Axis 3 (Relevant Physical Disorders)
Struggling with symptoms, husband in hospital, aging, retired - Axis 4 (Psychosocial Stressors)
Global Assessment of Functioning - Axis 5 (score 21-30 due to presence of hallucinations/delusions which influence behavior)
Multi-axial System DSM-IV Diagnosis
Delirium Due to Multiple Etiologies and a General Medical Condition
Confused, disoriented & out of touch with surroundings
acute symptoms - develop over hours or days
head injury, medication reactions, poisons & drug withdrawal related to delirium
meds with anticholinergic effects associated with severe delirium
often misdiagnosed - Emergency physicians missed delirium in 76% of cases (Han et al., 2009)

Differential Diagnosis cont'd
ruled out bipolar (age of onset is early adulthood)
ruled out depression (no history of previous depression & medication did not treat depressive symptoms)
By: K.Lee Haringa &
Maureen Moreau

Theoretical Perspective
Integrative Approach

Behavioural - observable symptoms
Cognitive - memory/thinking
Biological - medical/MRI
Psychosocial - social/environmental factors
Full transcript