Differential diagnosis and therapy of delirium

Delirium (i.e., acute confusional state) is a frequent syndrome due to different exogenous (physical, chemical or biological) factors. The prevalence of delirium increases with higher age (e.g., signs indicative of dementia) and particularly in those patients with severe somatic illness. Symptoms of delirium are considerably uniform irrespective of different etiological causes. However, delirium is frequently underrecognised which may lead to several complications. The article summarizes data on symptomatology, aetiology and pathogenesis of delirium. In addition syndromes sharing phenomenology similar with delirium are discussed and treatment recommended.     

Diagnostic evaluation of urinary incontinence in geriatric patients

In most cases, the evaluation of urinary incontinence requires only a history, a physical examination, urinalysis and measurement of postvoid residual urine volume. The initial purposes of the evaluation are to identify conditions requiring referral or specialized work-up and to detect and treat reversible causes that may be present. If the patient does not appear to require referral and a reversible cause is not identified, the next step is to categorize the patient's symptoms as typical of either urge or stress incontinence and treat the patient accordingly. If treatment fails or a presumptive diagnosis of urge or stress incontinence cannot be reached, the final step would be to perform more sophisticated tests or refer the patient for testing to define the cause and determine the best treatment.     

Revised consensus 'Diagnosis of the dementia syndrome'

Dementia is a clinical syndrome and is diagnosed on clinical grounds. Various types can be distinguished: the Alzheimer-type, frontal lobe dementia and subcortical dementia syndromes. Neuropsychological examination can contribute to the clinical diagnosis. Differentiation from delirium and depression, which may co-exist with dementia, is necessary. Once a dementia syndrome has been diagnosed its cause has to be ascertained. Alzheimer's disease is the most common cause and can often be diagnosed clinically. The clinical suspicion of vascular dementia has to be confirmed by imaging methods. Drug intoxication may cause or contribute to dementia. Blood tests should be performed routinely, but EEG, CT or MRI, SPECT and genetic tests can be carried out on clinical indication. Subsequently the need for care of the patient has to be established, as well as the ability of the carers to meet it. Regular follow-up is necessary. A definite diagnosis can only be made post-mortem when neuropathological examination has been performed. The organisation of diagnosis in the dementia syndrome should preferably take place in specialised multidisciplinary teams.     

Factors that influence the further survival of patients who survive for five years after the diagnosis of cancer in childhood or adolescence

Acute confusional states and agitated delirium are among the most common psychopathologic disorders in the elderly. However, they are rarely reported in the course of infarcts in the territory of the posterior cerebral artery. This study involving thirteen patients aged more than 65 years suggests that acute confusional states from posterior cerebral artery infarcts are less rare than usually thought, although the diagnosis may be difficult during the acute phase. The risk factors are no different from those observed for infarcts in other cortical areas, suggesting that this syndrome is due to structural damage of the brain rather than the other, usual causes of confusion in the elderly (intoxications, dysmetabolic diseases or dementia). The recognition of acute confusional states from posterior cerebral artery infarcts and its distinction from other causes of confusion is important in elderly patients because of the different diagnostic, prognostic and therapeutic implications involved.     

Neuropsychiatric adverse effects of antiparkinsonian drugs. Characteristics, evaluation and treatment

Parkinson's disease (PD) is a progressive neurological condition that causes considerable disability in the elderly. Drugs used to treat PD, such as levodopa, offer symptomatic relief but often have neuropsychiatric adverse effects, most prominently psychosis and delirium. Aged patients and those with dementia are particularly vulnerable to these adverse effects. Evaluating PD patients with drug-induced neuropsychiatric adverse effects is made difficult by their complex clinical presentations. The treatment of drug-induced psychosis and delirium begins with manipulating the antiparkinsonian drug regimen, but this frequently worsens motor function. Atypical antipsychotics such as clozapine have been successfully employed to treat the psychosis without worsening the motor disability. Patient intolerance of clozapine therapy has prompted open-label studies with newer agents such as risperidone, remoxipride, zotepine, mianserin and ondansetron.     

Nephrolithiasis: acute management and prevention

The primary care physician has a responsibility not only to recognize and treat acute stone passage but to ensure that the patient with recurrent stones has metabolic evaluation and appropriate preventive care. Renal colic is typically severe, radiates to the groin, is associated with hematuria, and may cause ileus. About 90% of stones that cause renal colic pass spontaneously. The patient with acute renal colic should be treated with fluids and analgesics and should strain the urine to recover stone for analysis. Highgrade obstruction or failure of oral analgesics to relieve pain may require hospitalization; a urinary tract infection in the setting of an obstruction is a urologic emergency requiring immediate drainage, usually with a ureteral stent. Several approaches are available when stones do not pass spontaneously, including extracorporeal shock wave lithotripsy, percutaneous lithotripsy, and ureteroscopic laser lithotripsy. Calcium stone disease has a lifetime prevalence of 10% in men and causes significant morbidity. Renal failure is unusual. Stone types include calcium oxalate, uric acid, struvite, and cystine. Stone analysis is particularly important when a noncalcareous constituent is identified. The majority of patients with nephrolithiasis will have recurrence, so prevention is a high priority. High fluid intake is a mainstay of prevention. Metabolic evaluation will indicate other appropriate preventive measures, which may include dietary salt and protein restriction, and use of thiazide diuretics, neutral phosphate, potassium citrate, allopurinol, and magnesium salts. Dietary calcium restriction may worsen oxaluria and negative calcium balance (osteoporosis).     

Metabolic encephalopathy as a complication of renal failure: mechanisms and mediators

Among patients with end-stage renal disease, nervous system dysfunction remains a major cause of disability. Patients with chronic renal failure who have not yet received dialysis may develop symptoms ranging from mild sensorial clouding to delirium and coma. Dialysis itself is associated with at least three distinct disorders of the CNS: dialysis disequilibrium syndrome; dialysis dementia; and progressive intellectual dysfunction. Peripheral neuropathy is also a major cause of disability in uremic subjects. It is believed that aluminum contributes to the pathogenesis of dialysis dementia. Biochemically, brain calcium is elevated in patients with renal failure, probably because of actions of parathyroid hormone on the brain. The diagnosis of dialysis disequilibrium syndrome, intellectual dysfunction, dialysis dementia, and uremic neuropathy can be made by the characteristic clinical pictures of these syndromes and the exclusion of other causes of nervous system dysfunction.     

The course of geriatric depression with "reversible dementia": a controlled study

OBJECTIVE: The goals of this longitudinal investigation were 1) to study the rate of development of irreversible dementia in elderly depressed patients with a dementia syndrome that subsided after improvement of depression and 2) to compare it with that of depressed, never-demented patients. METHOD: The subjects were 57 elderly patients consecutively hospitalized for major depression. At entry into the study, 23 subjects also met criteria for "reversible dementia," while 34 were without dementia. After a systematic clinical evaluation, the subjects were followed up at approximately yearly intervals for an average of 33.8 months. RESULTS: Irreversible dementia developed significantly more frequently in the depressed group with reversible dementia (43%) than in the group with depression alone (12%). Survival analysis showed that the group with reversible dementia had a 4.69-times higher chance of having developed dementia at follow-up than the patients with depression alone. No clinical characteristics at entry into the study were found to discriminate the subjects who developed irreversible dementia during the follow-up period from those who remained nondemented. CONCLUSIONS: These findings suggest that geriatric depression with reversible dementia is a clinical entity that includes a group of patients with early-stage dementing disorders. Therefore, identification of a reversible dementia syndrome is an indication for a thorough diagnostic workup and frequent follow-ups in order to identify treatable neurological disorders.     

Detection of abdominal adhesions in laparoscopic surgery. A controlled study of 130 cases

Clinical observation: A 67-year-old female patient operated of a severe aortic esthenosis with extracorporeal circulation during cardiac surgery, developed psychiatric disturbances with excitement and delirium, being necessary internamtient in a psychiatric ward, a month later. The evolution was right after neuroleptic treatment and nowdays she's assimptomatic. We review what is wrote about posteparative cognitive dysfunction (POCD), being this a tardive presentation case. We analize the definition, prevalence, etiology, pathofisiology, treatment and prevention since it is a reversible surgery complication but if it isn't early diagnosed and treated, its morbidity and mortality can be high.     

Notch3 mutations in CADASIL, a hereditary adult-onset condition causing stroke and dementia

Stroke is the third leading cause of death, and vascular dementia the second cause of dementia after Alzheimer's disease. CADASIL (for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) causes a type of stroke and dementia whose key features include recurrent subcortical ischaemic events and vascular dementia and which is associated with diffuse white-matter abnormalities on neuroimaging. Pathological examination reveals multiple small, deep cerebral infarcts, a leukoencephalopathy, and a non-atherosclerotic, non-amyloid angiopathy involving mainly the small cerebral arteries. Severe alterations of vascular smooth-muscle cells are evident on ultrastructural analysis. We have previously mapped the mutant gene to chromosome 19. Here we report the characterization of the human Notch3 gene which we mapped to the CADASIL critical region. We have identified mutations in CADASIL patients that cause serious disruption of this gene, indicating that Notch3 could be the defective protein in CADASIL patients.     

Diagnosing psychiatric emergencies in the elderly

Psychiatric emergencies in the elderly form a small percent of all elderly patients treated in emergency departments. However, accurately diagnosing and understanding behavioral emergencies in the elderly is difficult. Emergency behavioral syndromes in the elderly include confusion, agitation, psychosis, and behavioral regression. Causes of these syndromes in the elderly include delirium, dementia, medication side effects, physical illnesses, depression, and alcohol intoxication/dependency. Emergency physicians should consider each of these diagnostic possibilities when evaluating elderly behavioral emergencies to properly diagnose and treat elderly patients.     

Revisiting the O complex: urinary incontinence, delirium and polypharmacy in elderly patients

Urinary incontinence, delirium and polypharmacy are common, challenging problems encountered in elderly patients. Review of the literature shows that these conditions are interrelated. For example, polypharmacy can lead to delirium, which, in turn, can lead to urinary incontinence. The drugs prescribed for urinary incontinence can precipitate delirium or contribute to polypharmacy. The underlying causes for these problems in elderly patients are frequently complex, and management in turn must often be multifactorial. The occurrence of these problems should lead to careful evaluation followed by thoughtful, responsive treatment. Brief updates are given with recommendations for management directed at primary care physicians.     

AIDS-related dementia

Dementia is a common process in which there is gradual decrease in mental function due to disease of either cortical or subcortical structures. The numerous causes of dementia can be divided into those in which dementia is the primary manifestation, as in Alzheimer's disease, or secondary to chronic disease, neoplasms, endocrine and metabolic disorders and chronic infections. The dementia in AIDS is usually part of the syndrome of acquired immunodeficiency and may be its first manifestation.     

Validation of a cognitive test for delirium in medical ICU patients

Patients with delirium, dementia, depression, and schizophrenia were administered a newly developed test designed to identify delirium in an intensive care unit (ICU) setting. Two alternate forms of the Cognitive Test for Delirium (CTD) were highly correlated. The delirium patients performed least well, and an optimal cutoff score derived from relative-operating characteristic analysis resulted in a sensitivity of 100% and a specificity of 95%. In a follow-up study, the Mini-Mental State Exam could not be administered to 42% of the ICU patients who completed the CTD. Early identification of delirium with the CTD may lead to timely treatment of specific etiologic conditions and a reduction in mortality and morbidity.     

Pathophysiology of female lower urinary tract dysfunction

Urinary incontinence is a disorder with widely varying severity, patient symptoms, and etiologies. Urine loss can be because of reversible or irreversible systemic disease, abnormalities of urine storage, or voiding phase disorders. The optimal work up of an individual incontinence may include evaluation of neurologic, muscular, and urogenital systems, as well as medical, pharmaceutical, environmental, and psychosocial issues.     

Dementias--diagnosis, differential diagnosis and therapy

The most common cause of primary (degenerative) dementia in old age is Alzheimer's disease, with vascular forms of dementia taking second place. Endocrinopathies, normal pressure hydrocephalus and space-occupying lesions are frequent causes of secondary dementia. A multitude of further, more rare clinical presentations results in a wide differential diagnostic spectrum necessitating a careful diagnostic work-up of the demential syndrome before considering treatment. This work-up must include clinical, laboratory and equipment-based investigations. The multimodal therapeutic approach to dementia covers not only the elimination of treatable underlying causal conditions and the medical treatment of cognitive symptoms and psychiatric accompanying symptoms, but also non-medicamentous aspects.     

Fever in the returned traveler

The most important cause of fever in the returned traveler is malaria. All febrile patients in which malaria is epidemiologically possible require urgent evaluation for P. falciparum malaria, which can be rapidly fatal in the nonimmune patient. Early diagnosis and therapy can prevent severe morbidity and mortality. Other less common causes of undifferentiated fever include acute schistosomiasis, the enteric fevers, rickettsial diseases, leptospirosis, and dengue fever. Early empiric therapy for suspected leptospirosis and the rickettsial infections is encouraged to decrease morbidity and mortality. About a quarter of febrile patients do not have an etiologic agent determined for their illness but recover without sequelae. Patients with fever and hemorrhagic manifestations within 3 weeks of their return need to be isolated for the remote possibility of a highly transmissible agent. Although the febrile traveler is always a challenge, the real world differential diagnosis is limited and a systematic approach via the history, physical examination, and selected laboratory tests is usually sufficient to confirm the diagnosis or eliminate potentially serious infections.     

A small exploratory study of the reaction of older people to an episode of delirium

Delirium or an acute confusional state, occurs as a result of disease or physiological imbalance secondary to impaired brain function. One of its main clinical features is widespread cognitive impairment, which causes patients to become disconnected from their immediate surroundings and misinterpret reality. It has a sudden onset and its duration is relatively brief. Some authors take the view that delirium might be interpreted as a precursor to dementia. The aim of the study was to retrospectively explore older peoples' experience of an episode of delirium. In particular, whether they knew what had caused and cured it; and whether it had left them with any unresolved feelings of anxiety. A cross sectional design using grounded theory methodology was chosen, as being the most appropriate method for exploring this issue. A sample of 19 patients was selected using predetermined criteria, and engaged in a semi-structured interview with the researcher, in the ward environment. The interviews were audiotaped, transcribed, and analysed using the constant comparison method. Those interviewees who had illusions and hallucinations, were often able to describe their experiences in detail. They ranged from being pleasant and entertaining, to horrible and frightening. They were also able to remember short verbal commands from nurses during the episode of altered perception. Others remembered, or chose not to remember, very little. Few interviewees appeared to know exactly what had caused and cured the delirium, although some were able to tentatively connect the experience to their present medical condition. There also appeared to be little evidence of therapeutic communication with nursing staff once the episode of delirium had resolved. Although no one connected the experience with dementia, there did seem to be some evidence of mildly disturbed feelings, on reflecting back over the episode. As interviewees were generally willing to discuss their experiences with the researcher, it suggests that it would be helpful for nurses to provide opportunities to do so. Nevertheless, interviewees appeared to regard the episode simply as a transitory event in the overall context of illness, admission to hospital and their future welfare. The latter was of prime concern; yet again it appeared that they did not always receive the information they required to maintain control over their personal destinies.