This document discusses delirium in geriatric psychiatric patients. It begins with two case studies of elderly patients presenting with delirium and provides the DSM-5 and ICD-10 diagnostic criteria for delirium. It then discusses how delirium is underrecognized, especially in psychiatric settings where its symptoms can overlap with primary psychiatric disorders. Risk factors for delirium in this population include cognitive impairment, medical illnesses, and medications. The document emphasizes that delirium is a medical emergency that requires prompt treatment to prevent permanent brain damage and higher mortality. Prevention through careful management of risk factors is important.
Metabolic encephalopathy diagnosis and managementRobert Robinson
Overview of the diagnosis and management of metabolic encephalopathy for third year medical students in the Personalized Education Program portion of the third year curriculum at SIU Medicine
Metabolic encephalopathy diagnosis and managementRobert Robinson
Overview of the diagnosis and management of metabolic encephalopathy for third year medical students in the Personalized Education Program portion of the third year curriculum at SIU Medicine
This slide contains information regarding psychosis.This can be helpful for proficiency level and bachelor level nursing students. Your feedback is highly appreciated.
This slide contains information regarding psychosis.This can be helpful for proficiency level and bachelor level nursing students. Your feedback is highly appreciated.
As we are getting further from the 20th century many historical facts become clearer and clearer. Looking at the past century in perspective helps us to figure out our way forward. Jung and Frankl urged humanity to assimilate the devastation of the two World Wars by taking personal responsibility, and become aware of our projections, such as nationalism. They insist that reason is not enough to prevent future tragedies. These post-World War issues were never dealt with by humanity, just swept under the rug, as in the second half of the 20th century psychiatry identified
with psychopharmacology. Moreover, psychology's self-imposed limitation to the cognitive domain alone, neglecting the study of emotion or introspection is setting the stage for the 21st century repetition of history. The idea is that the current trajectories of both psychiatry and psychology are unsustainable as they direct us towards polarization, thus opening the way for the terrible enantiodromia. The events world-wide such as geographical fragmentation and failure of the nation states are proofs that we, humans have not dealt with our dormant demons.
important points regarding ICU psychosis, role of dexmedetomidine in it's treatment, mortality associated with delirium, symptomatic and definitive management
Schizophrenia is a significant mental disorder in which people interpret reality abnormally & it may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning. Through this period Anti psychotic & Psycho social treatment improve the condition.
The word delirium means “out of one’s furrow” which refers to the dramatic behavior changes that the person may experience. Some have called delirium "brain failure” because it may represent a variety of caused such as heart failure does in cardiac health.
Delirium is an outcome of a general medical condition, head injury and drug intoxication or withdrawal.
Late onset mania is a kind of Psychiatric illness in which Manic symptoms develops for the first time after the age of 60 years or the continuation of recurrent bipolar illness.
An overview of dementia gives an introduction to epidemiology, causes, clinical features, investigations, diagnosis, and management of dementia. Also a short description of related topics like difference between cortical and sub cortical dementia, psuedo dementia, mild cognitive impairment and reversible causes of dementia is also included.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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2 Case Reports of Gastric Ultrasound
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. Adonis Sfera, MD and Luzmin Inderias, MD
Preventing Delirium in Geroforensic
Population
2. Q&A
Polydipsia or hypodipsia (drinking too much or not
enough fluids) may lead to acute delirium
True/False
Urinary tract infections may precipitate an
exacerbation of schizophrenia
True/False
Hypoactive delirium is easily differentiated from
major depressive disorder
True/False
3. Memo
Delirium is a medical emergency which causes
permanent brain damage if not managed quickly and
correctly.
Most clinicians currently under-recognize delirium,
potentially harming our patients.
Prevention and treatment of delirium requires a true
interdisciplinary approach, and is worth the effort as it
saves lives!
4. The goal of this lecture
Consider delirium in your differential.
5. Outline
Vignettes
Definition
Delirium in psychiatric inpatients
Uncharted territory: delirium in geroforensics
Why does delirium happen
Recognising it
Risks and precipitants
Prevention is better than cure
Hydration and delirium
6. CASE 1
LF is a 63 years old patient with history of
schizophrenia and several medical problems
including chronic kidney disease with sodium
imbalance, HTN and cardiac pacemaker.
In January LF was transferred to the acute hospital
due to impaired awareness and cognition which
developed over a short period of time, resulting in
patient’s getting agitated and pulling his catheter
out.
LF’s history and clinical presentation meet the DSM
V criteria for acute delirium.
7. CASE 2
67 years old female with history of schizoaffective
disorder and mild cognitive impairment. Medical
problems: hypertension, hyperlipidemia and
obesity.
Became combative, agitated and confused with
both visual and auditory hallucinations.
PRN medication given consisting of haloperidol,
lorazepam, followed by increase in agitation.
Diagnosed with UTI.
8. Definition
Delirium is an age-related neurobehavioral syndrome
also called acute confusional state or acute brain failure.
Its manifestations consist of fluctuating cognition,
deficits of attention, disorganized or violent behavior,
altered sleep-wake cycle, hallucinations and delusions.
ENGEL GL, ROMANO J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis. 1959 Mar;9(3):260-77).
9. The history
Hippocrates (5 BC)
Hippocrates referred to delirium as “phrenitis” from
which we derive the word frenzy.
“As the motion of the arms I observe the
following facts: in acute fevers, pneumonia,
phrenitis and headache, if they move before the
face, hunt in empty air, pluck nap from the
bedclothes, pick up bits and snatch chaff from
the walls - all these signs are bad, in fact deadly.”
Hippocrates (Prognostic, XXII)
Phrenitis was replaced with the word delirium in
1769
10. Delirium in literature
After being rejected by his daughters and exposed to the storm, king Lear
becomes delirious, perhaps by cerebral vascular disease.
He recovers slightly before his death and is reconciled with his youngest
daughter, Cordelia.
11. The frenzy (delirium)of Orlando Furioso
Renaissance Italian poet Lodovico Ariosto (1516)
describes the frenzy (delirium) of Orlando Furioso
after not sleeping or eating for three days probably
resulting in dehydration and electrolyte imbalance:
“He neither sleeps nor eats; though three days pass,
Three times the dark descends, he has not stirred.
His grief so swells, his sorrow so amass
The madness clouds him, in which long he erred.
……………………………………
O miracle,
His intellect returned to its pristine
Lucidity as brilliant as before,
As his fair discourse latter witness bore.”
(Canto XXXIX)
12. Delirium: DSM-5 Diagnostic Criteria
A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain,
and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a
few days), represents a change from baseline attention and awareness, and
tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g., memory deficit, disorientation,
language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not explained by another
preexisting, established, or evolving neurocognitive disorder and do not
occur in the context of a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal (i.e., due to a
drug of abuse or to a medication), or exposure to a toxin, or is due to multiple
etiologies.
13. ICD-10 types of delirium
F00-F09 Organic, including symptomatic, mental disorders
F05 Delirium, not induced by alcohol or other psychoactive
substances
F05.0 Delirium, not superimposed on dementia
F05.1 Delirium superimposed on dementia
F05.8 Other delirium
F05.9 Delirium unspecified
F10-19 Mental and behavioral disorders due to psychoactive
substance use
F1x.03 Acute intoxication, with delirium
F1x.4 Withrowal state with delirium
F1x.40 Without convulsions
F1x.41 With convulsions
14. Delirium matters, but why?
More than 7 million hospitalized Americans suffer from
delirium each year.
More than 60% of delirium cases are not recognized by
the health care system.
Predictor of poor prognosis
In hospitalized patients case fatality rates 25% to 35%
Higher hospital costs per day
Source: American Delirium Society https://www.americandeliriumsociety.org/
15. More reasons
60% longer hospital length of stay (LOS)
Reducing delirium LOS by one day: saves $1-2 billion
dollars/year
5 times higher nursing home placement
Source: American Delirium Society https://www.americandeliriumsociety.org/
16. Why is delirium under-recognized?
The diagnosis of delirium is missed 33-67% of the time.
Delirium may be the only presentation of severe illness in
older patients, for example:
“Silent” myocardial infarction presents with delirium in up
to 40% of cases.
25% of older people have no fever associated with
pneumonia, tuberculosis, endocarditis or sepsis, delirium
being the only manifestation.
13% of older bacteremic patients are afebrile, but may
present with delirium.
17. Epidemiology
In the US, the overall prevalence of delirium in the
community is 1–2%.
The incidence of delirium arising during a hospital
stay ranges from 6% to as high as 56%.
In geriatric neuropsychiatric patients the
incidence is 40-60%.
Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and
treatment. Nature reviews Neurology. 2009;5(4):210-220. doi:10.1038/nrneurol.2009.24.
20. Delirium in primary psychiatric disorders
The literature regarding delirium in severe psychiatric
disorders in is extremely scarce: a total of 8 studies
between 1996 and 2014.
The literature regarding delirium in geroforensic
population is nonexistent.
21. This is what we know
In the past individuals with schizophrenia and
schizophrenia-like disorders (SLD) did not live long
enough to develop age-related diseases (both
medical neuropsychiatric).
Medical complications and suicide contributed to a
20-30% shorter lifespan in this population.
Schizophrenia “survivors” are a new category of
individuals specific for our generation.
22. Delirium in psychiatric inpatients
Patients with severe psychiatric illness have many risk
factors for delirium, such as cognitive impairment (Gill
and Mayou, 2000).
Delirium is under-recognized in mental health setting
because its symptoms overlap with those of the primary
psychiatric illness.
The highest prevalence of delirium was found in
individuals diagnosed with bipolar disorder (35.5%),
schizoaffective disorder (15.8%), schizophrenia
(12.1%)(Ritchie et all. 1996).
23. Delirium in psychiatric inpatients
A recent nationwide retrospective study from Denmark
concluded that:
in psychiatric inpatients delirium is associated with
elevated mortality.
anticholinergic and sedative-hypnotic agents are the
most commonly associated with delirium.
the best predictors of delirium are cognitive impairment
and a previous history of delirium as 40% of patients with
delirium had more than one episode.
24. Delirium is frequently misdiagnosed
as a psychiatric condition
Delirium is under-recognized in psychiatric patients because its symptoms
overlap with those of the primary psychiatric disorder.
25. A patients’ experience of delirium
http://www.europeandeliriumassociation.com/patient-
video.html
Think of delirium in elderly patients with chronic
psychosis.
Delirium occurs in many hospitalized older patients and
has serious consequences including increased risk for
death and admission to long-term care facilities.
Wong et al. JAMA. 2010.
26. Chronic delirium
Previously delirium been characterized
as an acute, severe and reversible
condition.
However, symptoms may endure
despite treatment or resolution of the
precipitating factors, resulting in
permanent cognitive impairment.
Novel studies found that 18% of
patients had delirium at 6 months.
American Delirium Society https://www.americandeliriumsociety.org/
27. Post-delirium cognitive impairment
Most patients demonstrate persistent difficulties and only
rarely return to premorbid levels of functioning
Even young patients experience post-delirium cognitive
impairment.
https://www.youtube.com/watch?v=x0QlOesVP9A&feature=
youtu.be
28. Differential diagnosis
Delirium vs. Dementia
Delirium vs. mania
Delirium vs. acute paranoia
Delirium vs. depression
Delirium vs. psychosis
29. Delirium, dementia and exacerbation of psychosis
Clinical feature Delirium Dementia Exacerbation of
psychosis
Onset acute slow acute
Circadian course fluctuating stable stable
Level of consciousness affected spared spared
Attention impaired impaired may be impaired
Cognition impaired impaired may be impaired
Hallucinations usually visual often absent usually auditory
Delusions poorly systematized often absent sustained and
systematized
Psychomotor activity increased or reduced often normal variable
Involuntary movements Asterixis, myoclonus,
tremor
absent absent
EEG abnormal abnormal Usually normal
30. Clinical type of delirium Symptoms Resembles
Hyperactive Increased arousal
Restless,
Agitated
May be aggressive
Mania
Psychotic
decompensation
Hypoactive Decreased alertness
Slow speech
Apathetic
Depression
Mixed Combination of the
above
Rapid cycling
32. Delirium in the geroforensic population
Forensic detainees represent a special population.
33. Schizophrenia predisposes to dementia
- Patients with schizophrenia and schizophrenia-like psychoses develop
late life dementia more often than the general population.
-Cognitive impairment is a feature of schizophrenia.
-Kraepelin used the term “dementia praecox” to describe schizophrenia.
-Over 25% of elderly with schizophrenia have moderate to severe
cognitive impairment.
Raghavakurup Radhakrishnan, Robert Butler, Laura Head. Dementia in schizophrenia. Advances in Psychiatric Treatment Mar
2012, 18 (2) 144-153; DOI: 10.1192/apt.bp.110.008268
34. The number of inmates over the age of 65 has more
than doubled between 2007 and 2013
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2007 2013
15,500
31,854
Source: Bureau of Justice Statistics
35. Geroforensic population more predisposed to delirium
than nonforensic seniors
forensic detainees age more rapidly than the general population
maintained on higher doses of psychotropic drugs
lowering medication dosages often delayed to avoid relapse of aggression
more likely to have history of unhealthy life styles and of drugs or alcohol
addiction
obesity more likely: altered volume of distribution of antipsychotic drugs
more likely hepatitis c, altering albumin level and hepatic drug metabolism
36. Why care about delirium in geroforensic
population?
Forensic institutions house individuals with severe
psychiatric disorders and significant history of
violence maintained on psychotropic drugs for
extended periods of time which predisposes this
population to adverse effects.
Psychotropic drugs may impair both the hydration
status and thermoregulation, predisposing for
medication adverse effects.
37.
38. Drug adverse effects
Dementia and aging are the main risk factors for
delirium.
Patients with dementia-delirium co-morbidity present
with a mortality risk of 65%.
Dementia and aging are crucial for the development of
medication adverse effects which occur in over 15% of
older patients at an annual cost of 20 billion .
Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. (2013)
87(5):331-6.
39. Medication adverse effects as risk factors of
delirium in psychiatric inpatients
Anticholinergic medications
ECT
Lithium-antipsychotic combination
High doses of low potency antipsychotic
drugs(Huang et al. 1998)
Non-psychiatric medications including antibiotics
Delirium may be a complication of treatment or
discontinuation of treatment with psychotropic
drugs (Kruszewski et al. 2009)(Lin and Ceo 2010).
40. Medications and aging
The effects of medications in older adults is a new field
of study, even though more than one-half of all
prescription medications are dispensed to persons older
than 60.
Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. (2013)
87(5):331-6
41. The Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults
A guideline for healthcare professionals to help improve the
safety of prescribing medications for older adults.
It emphasizes risk-benefit ratio, polypharmacy, drug-drug
interactions and adverse drug reactions.
The criteria are used in geriatrics clinical care to monitor and
improve the quality of healthcare.
The "Beers Criteria" contains lists of medications that pose
potential risks outweighing potential benefits for people 65 and
older.
By using Beers criteria practitioners may prevent harmful side
effects, including those that could be life-threatening.
Source: American Geriatric Society http://www.americangeriatrics.org
42. Antibiotics and delirium: a recent link
A recent study demonstrated that antibiotic toxicity can represent an unrecognized cause
of delirium in hospital patients, with manifestations observed in three distinct phenotypes:
1. encephalopathy accompanied by seizures or myoclonus arising within days
after antibiotic administration (caused by cephalosporins and penicillin);
2. encephalopathy characterized by psychosis arising within days of antibiotic
administration (caused by quinolones, macrolides, and procaine penicillin)
3. encephalopathy accompanied by cerebellar signs and MRI abnormalities
emerging weeks after initiation of antibiotics (caused by metronidazole).
Shamik Bhattacharyya, R. Ryan Darby, Pooja Raibagkar, L. Nicolas Gonzalez Castro, Aaron L. Berkowitz. Antibiotic-associated encephalopathy. Neurology
(2016) vol. 86 no. 10 963-971. doi: http://dx.doi.org/10.1212/WNL.0000000000002455
43. UTI and schizophrenia
Novel study: urinary tract infections 29 times more
likely in schizophrenia relapse.
Most likely mechanism: delirium
Miller BJ, Graham KL, Bodenheimer CM, Culpepper NH, Waller JL, Buckley PF. A prevalence study of urinary tract infections in acute relapse of schizophrenia.
J Clin Psychiatry. 2013 Mar;74(3):271-7. doi: 10.4088/JCP.12m08050.
45. The bottom line
Under-recognition of delirium in geroforensic
institutions translates into poorer health care outcomes in
spite of higher medical spending.
46. Aging and hydration
Homer: “old age is like a dried olive branch”.
Aristotle: “one should know that living beings are
moist and warm . . . However old age is dry and cold.”
Galen: “Aging is associated with a decline in innate
heat and body water.”
Galen’s most pertinent observation was that
dehydration is difficult to diagnose, and this remains
true today.
47. Dehydration and morbidity
Dehydration is a predisposing factor for delirium
Dehydration has been associated with increased mortality
rates among hospitalized older adults.
Dehydration is one of the ten most frequent diagnoses
responsible for hospitalization in the United-States.
Dehydration has been associated with impaired cognition,
acute confusion, falls and constipation.
The cost associated with dehydration in the US is estimated
at $1.14 billion a year.
Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam
Physician. (2013) 87(5):331-6
48. Hydration, cognition and psychopathology
Persistent subclinical dehydration is associated with
anxiety, panic attacks, and agitation.
Fluctuation in tissue hydration results in inattention,
hallucinations, and delusions.
Severe dehydration leads to somnolence, psychosis, and
unconsciousness (loss of awareness of the
surroundings).
CNS symptoms are present when dehydration results in a
1% loss of body water and are very prominent at 5% loss.
Breitbart W and Alici Y. Agitation and delirium at the end of life: “we couldn’t manage him”. JAMA. 2008;300(24):2898-2910.
49. Polydipsia or hypodipsia
Polydipsia and hypodipsia (drinking to much or not
enough water) are encountered in individuals with
history of schizophrenia or schizophrenia-like
psychosis.
Both predispose to electrolyte imbalance and
delirium.
Both are regulated by the same brain area, the
subfornical organ (SFO).
50. The thirst center: subfornical organ (SFO)
Adonis Sfera, Michael Cummings, Carolina Osorio. Dehydration and cognition in geriatrics: a hydromolecular hypothesis. Front. Mol. Biosci., 12 May 2016
| http://dx.doi.org/10.3389/fmolb.2016.00018
51. Further research in geroforensic delirium
It is necessary to answer the question: which
individuals require low dosage regimens of
psychotropic drugs in order to avoid age-related
adverse effects and which need and can tolerate
larger doses to avoid relapses into aggressive
behavior?