Which one of the following is the medical treatment of choice for acute delirium in the intensive care unit?
Correct Answer A:
Intravenous haloperidol has been found to be more effective than lorazepam and has minimal physiologic side effects. Chlorpromazine can worsen confusion and lower blood pressure. Droperidol can cause akathisia. Diphenhydramine can increase confusion due to its anticholinergic effects.
An 87-year-old black female is admitted to your hospital with a hip fracture. She lives alone and has been self sufficient. She has been able to drive, go to the grocery, and balance her own checkbook. She does well in the hospital until the second postoperative day, when she develops agitated behavior, tremor, and disorientation. She attempts to remove her Foley catheter repeatedly. She exhibits alternating periods of somnolence and agitation, and describes seeing things in the room that are not there.
Which one of the following is the most likely diagnosis?
This individual is exhibiting symptoms of delirium. Diagnostic criteria for delirium, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), include the following:
In the case described, the patient’s history does not indicate preexisting problems and she had a relatively abrupt onset of disturbance of consciousness and change in cognition, related to the hospitalization for hip fracture.
An 83-year-old female is admitted to the hospital with an exacerbation of her COPD. On the second hospital day she is clinically improved but is quite disorientated, experiencing visual hallucinations, agitation, and problems with recent memory and attention span. She is noted by the nursing staff to periodically fall asleep during conversation. Her previous medical history is notable for emphysema and hypertension, but there is not history of psychiatric problems. Her blood pressure is 140/82 mm Hg, pulse 88 beats/min, and oxygen saturation 98% on 2 L of nasal O2.
Which one of the following does this patient most likely have?
Correct Answer D:
The primary distinguishing feature of delirium is a course that is typically acute, with rapid deterioration over hours or days, rather than months as with dementia. Also, the severity of delirium tends to fluctuate over the course of hours, with patients appearing quite normal at time and wildly agitated with hallucinations at others. Frequently, extreme changes in psychomotor activity are noted with delirium; although this may also be seen with dementia, it is typically not seen until the latter stages. Bipolar disorders are characterized by the occurrence of mania, which is manifested by a full-blown disturbance of mood together with elation and irritability. Its onset is generally in the third or fourth decade of life. Schizophrenia, while often including hallucinations and delusions, usually starts in late adolescence or early adulthood, with a prodromal phase showing a gradual deterioration in function.
Which one of the following is the leading risk factor for delirium?
Correct Answer C:
The cause of delirium is typically multifactorial. The development of delirium involves the complex interaction between the vulnerable patient (one with predisposing factors) and exposure to precipitating factors.
Delirium affects 10%-30% of hospitalized patients who are medically ill. The prevalence is even higher in certain subgroups. For example, 25% of hospitalized patients with cancer, 30%-40% of hospitalized patients with HIV infection, and more than 50% of postoperative patients develop delirium during hospitalization. Among nursing-home residents older than 75, up to 60% may have delirium at any time.
Dementia is the leading risk factor for delirium, and fully two-thirds of delirium cases occur in patients with dementia. The underlying vulnerability of the brain in patients with dementia may predispose them to the development of delirium as a result of insults related to acute medical illnesses, medications, or environmental changes.
Unless the physician recognizes that dementia is a risk factor for delirium, the confusion and agitation associated with delirium can mistakenly be attributed to preexisting dementia. This can lead to a failure to search for underlying medical conditions or to discontinue medications that may be causing the delirium.
A 35-year-old female complains that her nose is too large, even after having cosmetic surgery on her nose three times. She has a minimal social life because of her concern about the appearance of her nose. A physical examination, including her appearance, is normal.
What is the most likely diagnosis?
The diagnostic criterion for body dysmorphic disorder is preoccupation with an imagined defect in appearance which causes significant distress of impairment in social, occupational, or other areas of function, and which is not better accounted for by another disorder. Obsessive-compulsive disorder, delusional disorder, and social phobia may accompany body dysmorphic disorder, but the history given is not specific for these disorders. Also, these disorders do not include preoccupation with a physical defect in their diagnostic criteria.
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