Psych Slides Week 5 - Schizophrenia & Delirium w Agitation (Previosuly ExDS)

Delirium (Acute Confusion)

• Acute, serious medical condition that produces temporary change in cognition and mental status

• Pt exhibits:

  • Disorientation

  • Hallucinations

  • Disorganized thinking

  • Paranoia and Delusions

• Pts struggle to focus

• Unable to have a conversation/be aware or surroundings

How does dementia differ from delirium?

It differs because delirium mainly affects attention and awareness and is much more acute (minutes or hours).

Temporary compared to dementia which is anatomical changes in the brain.

Those w dementia are 5x more likely to experience delirium.

3 Subcategories of Delirium

1. Hyperactive Delirium (w agitation): restless, extreme agitation, irritability, combative, hallucinations or delusions

2. Hypoactive Delirium: quiet, drowsy, lethargic, psychomotor retardation, often missed, by far the most common hype and highest mortality

3. Mixed Delirium: A mix of both symptoms

Delirium Risk Factors

• Acute brain condition (stroke, TBI)

• Chronic brain condition (dementia, Parkinson’s, etc.)

• Dehydration, constipation, or malnutrition

• Poor eye-sight or hearing

• Advanced cancers

• Metabolic Disturbances

• Medical Illness (UTI, sepsis, ICU)

• Changes in prescriptions (ex. withdrawal, prolonged use, new or added meds)ExDS

ExDS

• A group of signs and symptoms that includes a transient change in mental status and cognition associated w violent behaviour

• Very controversial

Delirium with Agitation

Syndromal disorder, which is controversial and highly debated precisely because the mechanism of lethality is unknown

Delirium (NOT A CRIME mneumonic)

N: naked (sweating, hyperthermia, temps up to 106)

O: objects (violence against)

T: tough and unstoppable; insensitive to pain

A: acute onset

C: confused about time, place, purpose

R: restrained and still won’t desist

I: incoherent

M: mental health conditions

E: early actions by EMS for rapid transport to ED

Hyperdoaminergia

• Produces extreme ‘fight or flight’ responses that result in large amounts of lactic acid from muscle activity resulting in metabolic acidosis

• Associated with:

  • Intense motor excitement

  • Paranoia

  • Bizarre

  • Often violent behaviour

Metabolic Acidosis

• Concern in ExDS

• Precise mechanism is unknown

• Exertion beyond normal physiological limits

• Resulting lactic acidosis may be a cause

• Increases RR to blow off CO2

Positional Asphyxiation

• Person is in prone position or pressire applied to chest or neck

• When person is held in position that restrict respirations during the restraint process

Main Causes of ExDS

1. Symptoms of psychosis and mania are both related to dopaminergic hyperactivity in brain circuits implicated in neuropsychiatry disorders

2. All psychostimulants (eg. coke, meth, MDMA) increase the synaptic levels of dopamine, which may explain why chronic psychostimulant abusers are more at risk

3. Extreme mental stress or an underlying, or perhaps undiagnosed psychiatric condition or even abruptly ceasing anti-psychotic medication

Death from ExDS

• CNS dopamine regulates heart rate, respiration, and core body temperature w chemical imbalance resulting in tachycardia, tachypnea, hyperthermia

• Hypothermia is a hallmark of ExDS and a forerunner of death

• Vctims of ExDS usually die from cardiopulmonary arrest