Delirium and Amnestic and Other Cognitive Disorders
The psychiatric conditions in this chapter are all caused by medical (organic) pathology. The most common is delirium, but several other specific presentations occur as well. In addition, gross organic processes contribute to dementia (see Chapter 6), intoxication, and withdrawal (see Chapters 16 and 17), and many of the syndromes found in other chapters.
These syndromes are common, particularly among the elderly (20% or more of all acute medical inpatients develop some organic syndrome, usually delirium). Delirium is acute, usually brief, and reversible, whereas dementia is of slower onset, longer lasting, and more likely to be irreversible, yet none of these characterizations is completely true (e.g., 15% to 20% of dementias are at least partially reversible). These conditions are clinically defined, and their course and characteristics depend on the nature, severity, course, and location of the causative organic pathology. First, identify the syndrome, and then determine the likely organic cause.
DELIRIUM
Delirium (1,2) is a common condition that may be caused by physical illness (D. DUE TO A GENERAL MEDICAL CONDITION, DSM, p. 141, 293.0), drugs (SUBSTANCE INTOXICATION OR WITHDRAWAL., DSM, p. 143), several causes simultaneously (D. DUE TO MULTIPLE ETIOLOGIES, DSM, p. 146), or by unknown organic conditions. These patients may be confused, bizarre, or even “wild,” and thus can be mistakenly thought to have other psychotic illnesses. Other delirious patients may appear somnolent or perfectly normal during the day but decompensate dramatically in the evening or night. Still other patients may have increasing difficulty functioning because of a mild delirium that is revealed only by specific mental status testing. Synonyms include acute brain syndrome, toxic psychosis, acute confusional state, and metabolic encephalopathy.
Diagnosis
Delirium is a rapidly developing disorder of disturbed attention that fluctuates with time. Although the clinical presentation of delirium differs considerably from patient to patient, several characteristic features help to make the diagnosis:
Clouding of consciousness: The patient is not normally alert and may appear bewildered and confused. Noticeably decreased alertness (grading into stupor) or hyperalertness may be present. Observe the patient.
Attention deficit: The patient usually is very distractible and unable to focus attention sufficiently or for a long enough time to follow a train of thought or to understand what is occurring around him. Have the patient do serial 7s or 3s and/or a Random Letter Test.
Perceptual disturbances: These are common and include misinterpretations of environmental events, illusions (e.g., the curtain blows, and the patient believes someone is climbing in the window), and hallucinations (usually visual). The patient may or may not recognize these misperceptions as unreal.
Sleep-wake alteration: Insomnia is almost always present (all symptoms are usually worse at night and in the dark), and marked drowsiness may also occur.
Disorientation: Most frequently to time but also to place, situation, and (finally) person. Ask for the date, time, and day of the week: “What place is this?” etc.
Memory impairment: The patient typically has a recent memory deficit and usually denies it (he or she may confabulate and may want to talk about the distant past). Ask about the recent past (e.g., “Who brought you to the hospital?” “Did you have any tests yesterday?” “What did you have for breakfast?”) Name four objects and two words, and ask the patient for them in 5 minutes. Does he or she remember your name?
Incoherence: The patient may attempt to communicate, but the speech may be confused or even unintelligible. Verbal perseveration may occur.
Altered psychomotor activity: Many delirious patients are restless and agitated, and some may display perseveration of motion, some may be excessively somnolent, and some may fluctuate from one to the other (usually restless at night and sleepy during the day).Related posts:
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