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Alcohol withdrawal
12%
14/118
Brief psychotic disorder
2%
2/118
Delirium
76%
90/118
Lewy body dementia
3%
4/118
Medication side effect
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This patient with a urinary tract infection is found to be alert and oriented on presentation, and then experiences a transient decline in mental status before quickly returning to baseline. This is most consistent with delirium in the setting of an infection of a hospitalized elderly patient. Delirium is a neurocognitive disorder marked by impaired awareness as well as decreased attention, memory, and perception. Symptoms develop quickly, and mental status tends to fluctuate throughout the day. Patients may also experience illusions and hallucinations with worsening severity at night (termed sundowning). Delirium most often occurs in the elderly and hospitalized patients. Common causes include infection, metabolic diseases, trauma, hypoxia, drugs and toxins, and sleep deprivation. If the cause of delirium is unknown, a workup for electrolyte and metabolic etiologies is warranted. Treatment requires identifying the underlying cause, discontinuation of causative medications, and supportive medical care. Importantly, precautions such as reducing exposure to polypharmacy, reorienting hospitalized patients often, and minimizing the amount of therapy/noise at night can reduce the risk of developing delirium. Incorrect Answers: Answer 1: Alcohol withdrawal first presents with sweating, insomnia, and tremors (within 3-36 hrs of cessation) and can progress to seizures and hallucinosis (12-48 hrs) and in severe cases delirium tremens (48-96 hrs). Delirium tremens includes altered mental status as seen in this patient but would also include seizures. Answer 2: Brief psychotic disorder is a psychotic condition that involves the sudden onset of at least 1 psychotic symptom (incoherence, delusions, or hallucinations) that lasts greater than 1 day but less than 1 month. Answer 4: Lewy body dementia is the second most common form of neurodegenerative dementia marked by dementia, extrapyramidal motor symptoms, and visual hallucinations. Dementia is progressive mental decline, not transient as seen in this patient. Answer 5: Medication side effects of delirium are common in anti-histamines, opioids, benzodiazepines, corticosteroids, and muscle relaxants. None of this patient's current medications are associated with delirium. Bullet Summary: Delirium is characterized by waxing and waning impaired attention and awareness with transient disruptions in memory, language, and perception.
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