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Infection
7%
2/29
Polypharmacy
0%
0/29
Amyloid accumulation
83%
24/29
Volume depletion
3%
1/29
Electrolyte abnormalities
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This clinical presentation is consistent with delirium, which is can be caused by a multitude of factors including infection, polypharmacy, drug side effects, and electrolyte abnormalities. CNS amyloid accumulation plays no role in delirium. It it important to recognize the differences in presentation between delirium and dementia. Delirium is clinical syndrome with an acute onset and waxing and waning course caused by an underlying medical condition, substance intoxication or withdrawal, or medication side effect; it is characterized by a disturbance in consciousness and reduced ability to shift attention. In dementia (such as Alzheimer's disease, characterized by amyloid accumulation in the central nervous system), changes in memory or intellect are slowly evident over the course of months or years, and alertness is generally spared and attentional deficits are often intact in the earlier stages of the disease. Clinicians must be especially wary of delirium in elderly patients, particularly in the post-operative state. Kalish et al. present an overview of the evaluation and management of delirium in elderly patients. Preventive interventions in patients who are at highest risk of delirium include frequent reorientation, early and recurrent mobilization, pain management, adequate nutrition and hydration, reducing sensory impairments, and ensuring proper sleep patterns. Clegg et al. present a review of the effectiveness of interventions for preventing delirium in older people in long term care settings. They identify one large cluster-RCT involving 3538 patients in which a computerized system that identified medications that may contribute to delirium risk was associated with a significant reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51). Illustration A presents a table with differentiating features between delirium and dementia. Illustration B presents a multicomponent approach to the management of delirium; use of antipsychotic medications is considered secondary to non-pharmacological approaches. Illustration C presents a mnemonic for the various underlying causes of delirium. Incorrect Answers: Answer 1, 2, 4, 5: All of these are potential contributing factors to the development of delirium.
4.3
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