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A neurology primer Descriptions exist prior to Hippocrates Phrenitis ◦ Acute transient mental disorder seen in association with medical illness, with psychomotor agitation, insomnia and disturbances of mood/perception Lethargus ◦ Somnolence, inertia, reduced response to stimuli An acute disorder characterized by disturbances in consciousness, disorganized thinking, fluctuating course with reduced ability to focus, sustain, or shift attention Develops over a short time Disturbances in cognition (memory, disorientation, perceptual/spatial disturbance) Acute confusional state Toxic/metabolic encephalopathy ICU psychosis Organic brain syndrome Hepatic encephalopathy Beclouded dementia “Sundowning” 20% of hospitalized elders 50% of hip fracture patients Annual costs ~ $8 billion dollars Results in longer hospital stays, morbidity, mortality, & nursing home placement 32-67% of cases never detected “The physician who is greatly concerned to protect the integrity of the heart, liver, kidneys of his patient has not yet learned to have the similar regard for the functional integrity of his patient’s brain” Romano & Engel 1959 J Chron Dis A syndrome with cognitive, psychiatric, and neurological manifestations Understanding the key elements of the syndrome is the most critical skill Remembering “laundry lists” of potential causes is not useful Read the nursing and therapy staff notes ◦ Often the consult is literally done before ever having to see the patient Listen to families & don’t tell them their loved one is “back to baseline” if they state otherwise Educate families & other medical staff Hypervigilant ◦ Frequently associated with drug intoxication/withdrawal (delirium tremens) with increased arousal and autonomic lability Hypovigilant or “quiet delirium” ◦ Somnolent, sluggish, and apathetic Mixed forms A disorder of attention (ability to maintain a coherent stream of thought, free of interference from external or internal stimuli) ◦ Sustained attention ◦ Divided attention ◦ Ability to inhibit irrelevant stimuli Disorientation, poor memory, visuospatial disturbances & language changes are in large part due to disordered attention (unless they pre-existed due to underlying dementia) Mood changes (depression, apathy, irritability, anxiety, & mania) Psychosis is common! ◦ Suspiciousness, paranoid delusions ◦ Visual hallucinations Delirium is the most common cause of new onset psychosis in the elderly Asterixis Action or postural tremor Impaired postural control (balance) Bowel and bladder incontinence Motor tone abnormalities (gegenhalten type rigidity) The neuroanatomy of attention/arousal is diffuse & vulnerable at many points Often the first to “fall apart” when elderly patients get ill for whatever reason Precipitating cause is seldom “in the brain itself”, such as a new stroke, brain tumor, bleed, or CNS infection CT scans, MRI scans, lumbar punctures are seldom useful and often red herrings If you got one, look at it (brain size, vasculopathy, hippocampal atrophy, ventricolomegaly) If you are completely unsure, then EEG is helpful but rarely needed Delirious patients have decompensation of other processes that rely on widely distributed neural networks (maintaining the upright posture and continence) Not surprisingly these recover together A person’s gait/balance may be just as good an indicator of recovery from delirium! Attention and arousal are dependent upon widely distributed neural circuitry and therefore vulnerable to a variety of insults The neurotransmitters acetylcholine (ACh) and dopamine seem particularly important Anticholinergic drugs cause delirium Cholinergic agonists reverse drug-induced delirium Lewy body dementia mimics delirium Hypoxia, hyperglycemia, thiamine deficiency cause decreased ACh release Alzheimer’s and other dementia at increased risk Serum anticholinergic activity correlates with delirium severity and incidence Dopamine agonists can cause delirium Dopamine blockade treats delirium Dopamine release increases in hypoxia Dopamine is important in prefrontal areas Dopamine density in prefrontal cortex decreases with aging and correlates with attentional measures Distractibility Poor persistence Tangentiality and rambling incoherence Intrusions of irrelevant information ◦ Results in inability to learn new information, solve problems or engage in goal-directed behavior “Patient is pleasantly confused” “He kept speaking of going to the circus, & had difficulty following directions” Patient stated “I want off this train. I am choking” “Patient is very sleepy, and difficult to arouse” Patient had a “rough night, was up all night and agitated” Digit span forwards and backwards ◦ Normal forwards is 7 +/- 2 ◦ Backwards usually 2 less than forward Reciting overlearned tasks ◦ Alphabet ◦ Months forward, days of week forward/backwards Counting 1-20 forwards, backwards Continuous performance task such as the “A” test ◦ Raise and lower hand in response to letter A Writing is extremely sensitive to delirium ◦ Draws on many complex skills and falls apart early Document the mental status examination including description of cognitive/affective features ◦ Record some test of attention (digit span, counting span, months forward, alphabet etc.) ◦ Describe mood/behavior (irritability, hallucinations, paranoia, apathy, mood lability, sadness, etc.) Document some neurologic exam (asterixis, action tremor, poor balance/instability) Studies CBC, CMP, urinalysis, pulse ox/ABG, EKG Physical examination Chest XRAY, other body imaging Sometimes drug screen, tsh, b12/folate, thiamine, lumbar puncture, neuroimaging ◦ EEG can be useful in unclear cases looking for diffuse slowing ◦ ◦ ◦ ◦ Medications! (perform a detailed review) Common geriatric infections (pneumonia, urinary tract infections, abdominal infections, cutaneous) Hip fracture Metabolic disturbances (glucose, sodium, calcium, acid-base) Hypoxemia CHF, myocardial ischemia Furosemide 0.22 Digoxin 0.25 Warfarin 0.12 Nifedipine 0.22 Isosorbide 0.15 Ranitidine 0.22 Theophylline 0.44 Prednisone 0.55 Codeine 0.11 Cimetidine 0.86 Correct/remove all contributing factors Provide meticulous supportive care (feeding, mobility, continence, pressure wounds) Engage patient/family provide reassurance Correct sensory deficits (glasses, hearing aids, avoid complete darkness) Falls alarm, sitter, family member Avoid too much or too little stimulation Try to improve sleep/wake cycle Avoid iatrogenesis (physical restraints) Plan for discharge, follow-up and next level of care Document your examination findings Antipsychotics are first line Benzodiazepines only for alcohol or drug withdrawal states Occasionally cholinesterase inhibitors may be useful and are likely to play an important role as new research evolves Avoid benzodiazepines except for alcohol/drug withdrawal ◦ Haloperidol recommended first line for most 0.5 mg q 3 ◦ Avoid older sedating antipsychotics (anticholinergic) ◦ Atypical antipsychotics Put on standing dose if requirement is frequent and supplement with prn Goal is to treat cognition/psychiatric dysfunction, not sedation! Haldol generally favored ◦ Can be given IM, SQ, IV, PR, PO ◦ Low doses in elderly frail patients 0.5 mg initially and then every 4 hrs ◦ Avoid in parkinsonian patients (need to recognize EPS) Increasing use of “atypical antipsychotics” ◦ Olanzapine, quetiapine, risperidone, ziprasidone Ensure not only medical but cognitive follow up as well Document your exam for others Anticipate it will recur in the future and try to optimize conditions so it will not Educate families about medications, and the syndrome of delirium Delirium is a common, costly and morbid condition Delirium is fundamentally a disorder of attention Delirium is poorly recognized Many patients have unrecognized preexisting dementia Many patients will ultimately develop dementia