Delirium: Assessment and Management — MCQs
Which of the following will have an organic cause?
Global cerebral dysfunction characterised by alteration in cognitive function and consciousness is known as
Which of the following statements is NOT true about delirium?
A young girl presents with a history of multiple episodes of loss of consciousness lasting for 20 minutes. These episodes occur only in front of family members and only during the daytime. There is no history of tongue biting or incontinence, and EEG and MRI studies are normal. What is the most appropriate management?
A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?
A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?
Which of the following conditions does not typically involve delusions?
The Confusion Assessment Method (CAM) is used for which of the following?
A 25-year-old uncooperative patient of schizophrenia was brought in to the casualty. The Casualty Medical Officer gave an injectable drug to the patient. Two hours later patient develops the following posturing. What is the best treatment?
The 4AT is a screening tool for detection of delirium. Which THREE of the following parameters listed below are included in the 4AT tool? I. Alertness II. Apnoea III. Abbreviated Mental Test (AMT4) IV. Attention Select the correct answer using the code given below:
Delirium: Assessment and Management Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following will have an organic cause?
- A. Schizophrenia
- B. Delirium (Correct Answer)
- C. Anxiety
- D. Obsessive compulsive disorder
Explanation: ***Delirium*** - Delirium is an **acute, fluctuating disturbance of consciousness** and cognition that is directly caused by a **medical condition**, substance intoxication/withdrawal, or medication side effect [1], [2], [3]. - It always has an **underlying organic etiology** such as infection, metabolic derangements, drug toxicity, or neurological disorders [1], [2]. *Schizophrenia* - Schizophrenia is a **chronic psychiatric disorder** characterized by psychosis (hallucinations, delusions), disorganized thinking, and negative symptoms. - While it has a neurobiological basis, it is considered a **primary mental illness** and not typically caused by an acute, identifiable organic illness in the way delirium is. *Anxiety* - Anxiety disorders are characterized by excessive worry, fear, and physical symptoms of arousal. They are considered **primary mental health conditions**. - Although stress can precipitate anxiety, it is not primarily due to a **specific acute organic cause** that resolves with treatment of that cause. *Obsessive compulsive disorder* - Obsessive-compulsive disorder (OCD) is an anxiety-related disorder characterized by **recurrent, intrusive thoughts (obsessions)** and repetitive behaviors (compulsions) aimed at reducing distress. - Like other primary mental health conditions, it has a neurobiological basis but is not classified as having an **acute organic cause** in the medical sense.
Question 2: Global cerebral dysfunction characterised by alteration in cognitive function and consciousness is known as
- A. Delirium (Correct Answer)
- B. Dementia
- C. Depression
- D. Acute anxiety
Explanation: ***Delirium*** - Delirium is characterized by an **acute onset** of global cerebral dysfunction, marked by fluctuations in **attention, consciousness, and cognition**. - It is a medical emergency that can be caused by various underlying medical conditions, medications, or substance withdrawal. *Dementia* - Dementia is a **chronic** and progressive decline in cognitive function, primarily affecting **memory, language, and problem-solving abilities**, without a primary disturbance of consciousness. - While it involves cognitive impairment, its onset is typically gradual, and it lacks the acute fluctuations and prominent consciousness alterations seen in delirium. *Depression* - Depression is a **mood disorder** characterized by persistent sadness, loss of interest, and other emotional and physical symptoms, which can affect concentration and memory. - It does not involve a primary alteration in consciousness or the acute, global cognitive dysfunction characteristic of delirium. *Acute anxiety* - Acute anxiety is a state of intense fear or uneasiness, often accompanied by physical symptoms like palpitations and shortness of breath. - While it can interfere with focus and concentration, it does not represent a global cerebral dysfunction or an alteration in consciousness in the way that delirium does.
Question 3: Which of the following statements is NOT true about delirium?
- A. Preserved attention (Correct Answer)
- B. Disorientation
- C. Hallucination
- D. Disturbed sleep
Explanation: ***Preserved attention*** - A core diagnostic feature of **delirium** is a disturbance of attention, meaning attention is **impaired**, not preserved. - Patients typically struggle to focus, sustain, or shift attention. *Disturbed sleep* - Delirium often involves a **disturbance of the sleep-wake cycle**, leading to insomnia during the night and drowsiness during the day. - This disorganized sleep pattern is a common symptom and can contribute to agitation or lethargy. *Disorientation* - Patients with delirium frequently exhibit **disorientation**, particularly to time, place, or person. - This reflects the global cognitive impairment characteristic of the condition. *Hallucination* - **Hallucinations**, particularly visual ones, are commonly experienced by individuals with delirium. - These perceptual disturbances contribute to the agitated or fearful presentation of some delirious patients.
Question 4: A young girl presents with a history of multiple episodes of loss of consciousness lasting for 20 minutes. These episodes occur only in front of family members and only during the daytime. There is no history of tongue biting or incontinence, and EEG and MRI studies are normal. What is the most appropriate management?
- A. Treat with aversive therapy
- B. Insight-oriented psychotherapy (Correct Answer)
- C. Valproate
- D. Ketogenic diet
Explanation: ***Insight-oriented psychotherapy*** - The presentation strongly suggests **non-epileptic seizures (NES)**, also known as **psychogenic non-epileptic seizures (PNES)**, which are usually of psychological origin. - **Insight-oriented psychotherapy** is the most appropriate management, aiming to address underlying psychological conflicts or stress that manifest as these episodes. *Treat with aversive therapy* - **Aversive therapy** is typically used for behavioral modification in conditions like substance abuse or paraphilias, where a negative stimulus is paired with an undesirable behavior. - It is not indicated for **psychogenic non-epileptic seizures**, where the underlying cause is psychological distress rather than a learned undesirable behavior. *Valproate* - **Valproate** is an **antiepileptic drug** used to treat various types of seizures, including generalized tonic-clonic and absence seizures. - Since EEG and MRI are normal, and the clinical features (no tongue biting/incontinence, specific timing/audience) rule out epilepsy, antiepileptic medication like Valproate is **inappropriate**. *Ketogenic diet* - The **ketogenic diet** is a high-fat, low-carbohydrate diet used as a medical treatment for **drug-resistant epilepsy**, particularly in children. - Given that the episodes are **non-epileptic** and investigations are normal, a ketogenic diet would be ineffective and unnecessary.
Question 5: A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?
- A. Alzheimer's disease
- B. Delirium (Correct Answer)
- C. Depression
- D. Post-traumatic psychosis
Explanation: ***Delirium*** - The **acute onset** of memory loss and confusion **2 days after cardiac bypass surgery** is characteristic of **postoperative delirium**. - Delirium is a disturbance in **attention**, **awareness**, and **cognition** that develops over a short period (hours to days) and is directly related to a medical condition or procedure. - **Cardiac surgery** is a well-known risk factor, with delirium occurring in **10-50%** of cardiac bypass patients due to factors like anesthesia, hypoperfusion, inflammation, and physiological stress. - Key features here: **acute onset**, **temporal relationship to surgery**, and **memory/cognitive deficits** without psychotic symptoms. *Alzheimer's disease* - Alzheimer's is a **chronic, progressive neurodegenerative disorder** with **gradual onset** over months to years. - The **sudden appearance** of symptoms immediately after surgery cannot be explained by Alzheimer's disease. - While Alzheimer's causes memory impairment, it does not present acutely in the postoperative setting. *Depression* - Depression can cause **pseudodementia** with cognitive complaints, but the primary features would be **persistent low mood**, **anhedonia**, **sleep disturbance**, and **appetite changes**. - The **acute temporal link** to surgery and absence of mood symptoms make depression unlikely. - Cognitive symptoms in depression are typically subjective complaints rather than objective deficits. *Post-traumatic psychosis* - This would involve **psychotic symptoms** such as **hallucinations**, **delusions**, or **disorganized behavior**, which are not described in this case. - The presentation of simple **memory deficits** without psychotic features does not support this diagnosis. - Surgery itself is not typically considered a psychologically traumatic event that would trigger psychosis.
Question 6: A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?
- A. Calcium administration
- B. Prophylactic carbamazepine administration
- C. Prophylactic phenytoin administration
- D. Prophylactic diazepam administration (Correct Answer)
Explanation: ***Prophylactic diazepam administration*** - The patient presents with symptoms highly suggestive of **Wernicke-Korsakoff syndrome** (memory loss, ataxia, nystagmus) superimposed on chronic alcohol abuse with a history of alcohol withdrawal, indicating a high risk for further withdrawal seizures or delirium tremens [1], [3]. - **Benzodiazepines** like diazepam are the cornerstone of treatment for alcohol withdrawal syndrome due to their anxiolytic, anticonvulsant, and sedative properties, preventing progression to more severe withdrawal manifestations [2]. *Prophylactic phenytoin administration* - **Phenytoin** is generally not recommended for the prevention or treatment of alcohol withdrawal seizures unless there is an underlying seizure disorder unrelated to alcohol. - Its efficacy in preventing recurrent alcohol withdrawal seizures is limited compared to benzodiazepines. *Prophylactic carbamazepine administration* - While **carbamazepine** can be used in some cases of alcohol withdrawal, particularly to reduce seizure risk and improve sleep, it is not considered first-line for acute prophylaxis against severe withdrawal or delirium tremens, especially in a patient with active tremulousness and autonomic hyperactivity. - Benzodiazepines offer a broader spectrum of action against the diverse symptoms of alcohol withdrawal. *Calcium administration* - There is no indication that the patient has a **calcium deficiency** or hypocalcemia related to alcohol withdrawal symptoms. - Calcium administration would not address the underlying neurochemical imbalances associated with acute alcohol withdrawal or the progression to Wernicke-Korsakoff syndrome.
Question 7: Which of the following conditions does not typically involve delusions?
- A. Delirium
- B. Alcohol withdrawal
- C. OCD (Correct Answer)
- D. Schizophrenia
Explanation: ***OCD*** - **Obsessive-compulsive disorder** is characterized by recurrent, intrusive **thoughts (obsessions)** and repetitive **behaviors (compulsions)**, which the individual typically recognizes as irrational. - While patients with severe OCD may have **poor insight**, they generally do not experience **delusions**, which are fixed, false beliefs held despite evidence to the contrary. *Delirium* - **Delirium** is an acute, fluctuating disturbance of consciousness resulting from medical conditions or substance intoxication/withdrawal, often accompanied by **psychotic symptoms** including **delusions** and **hallucinations**. - The rapid onset and global cognitive impairment make **delusions** a common feature. *Schizophrenia* - **Schizophrenia** is a severe mental disorder characterized by **psychotic symptoms**, with **delusions** being one of the hallmark positive symptoms. - These **delusions** often include **persecutory**, **grandiose**, or **somatic themes**, among others. *Alcohol withdrawal* - Severe **alcohol withdrawal** can lead to **delirium tremens (DTs)**, which is associated with **psychotic symptoms** such as **delusions** and vivid **hallucinations** (often visual or tactile). - These **delusions** are often **persecutory** or referential in nature and contribute to the patient's fear and agitation.
Question 8: The Confusion Assessment Method (CAM) is used for which of the following?
- A. Schizophrenia
- B. Delirium (Correct Answer)
- C. Dementia
- D. Depression
Explanation: ***Delirium*** - The Confusion Assessment Method (CAM) is a widely used and highly sensitive and specific tool for the rapid identification of **delirium**. - It assesses for acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. *Schizophrenia* - Schizophrenia is a chronic mental health disorder primarily characterized by **psychosis**, including hallucinations, delusions, and disorganized thought. - While patients with schizophrenia can experience cognitive difficulties, specialized scales like the Positive and Negative Syndrome Scale (PANSS) are used, not the CAM. *Dementia* - Dementia is a gradual and progressive decline in cognitive function, including memory, thinking, and reasoning, severe enough to interfere with daily life. - Tools like the mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA) are used for screening and assessing dementia, not the CAM. *Depression* - Depression is a mood disorder characterized by persistent sadness, loss of interest, and other emotional and physical symptoms. - Assessment tools like the Hamilton Depression Rating Scale (HDRS) or Patient Health Questionnaire-9 (PHQ-9) are used for depression.
Question 9: A 25-year-old uncooperative patient of schizophrenia was brought in to the casualty. The Casualty Medical Officer gave an injectable drug to the patient. Two hours later patient develops the following posturing. What is the best treatment?
- A. Propranolol
- B. Dantrolene sodium
- C. Ventriculostomy
- D. Benzhexol (Correct Answer)
Explanation: ***Benzhexol*** - The patient's posturing (likely **acute dystonia**) is a common extrapyramidal side effect of typical antipsychotics, which are often given via injection to uncooperative schizophrenic patients. - **Benzhexol** (trihexyphenidyl) is an anticholinergic medication used to treat drug-induced extrapyramidal symptoms like dystonia, parkinsonism, and akathisia. - In acute dystonia, **parenteral anticholinergics** (IV diphenhydramine or IM benztropine) are typically preferred for faster onset, but benzhexol remains a valid anticholinergic treatment option. - The anticholinergic action reverses the dystonic reaction by restoring the dopamine-acetylcholine balance in the basal ganglia. *Propranolol* - **Propranolol** is a beta-blocker primarily used to treat essential tremor and some forms of drug-induced akathisia, but it is not the first-line treatment for acute dystonia. - While it can help with anxiety symptoms associated with akathisia, it has no role in managing acute dystonic reactions. *Dantrolene sodium* - **Dantrolene sodium** is a direct-acting skeletal muscle relaxant primarily used in the management of **neuroleptic malignant syndrome (NMS)** and malignant hyperthermia. - NMS is a more severe and distinct adverse reaction, involving fever, muscle rigidity, altered mental status, and autonomic dysfunction, which is not depicted here. - Acute dystonia presents much earlier (hours) compared to NMS (days to weeks) and lacks the systemic features of NMS. *Ventriculostomy* - **Ventriculostomy** is a neurosurgical procedure to relieve hydrocephalus by draining cerebrospinal fluid from the ventricles of the brain. - This procedure is entirely unrelated to the management of drug-induced extrapyramidal side effects from antipsychotic medication.
Question 10: The 4AT is a screening tool for detection of delirium. Which THREE of the following parameters listed below are included in the 4AT tool? I. Alertness II. Apnoea III. Abbreviated Mental Test (AMT4) IV. Attention Select the correct answer using the code given below:
- A. I, III and IV (Correct Answer)
- B. I, II and IV
- C. I, II and III
- D. II, III and IV
Explanation: ***I, III and IV*** - The 4AT screening tool specifically includes **Alertness**, **AMT4 (Abbreviated Mental Test)**, and **Attention** as key parameters for detecting delirium. - The **AMT4** component assesses **cognitive function**, while **Alertness** and **Attention** evaluate the patient's state of consciousness and focus. *I, II and IV* - This option incorrectly includes **Apnoea**. While apnoea is a significant medical condition, it is not a direct parameter in the **4AT delirium screening tool**. - The 4AT focuses on cognitive and neurological signs of delirium, not respiratory patterns. *I, II and III* - This option also incorrectly includes **Apnoea** as one of the parameters in the 4AT tool. - The 4AT is designed to assess **delirium**, which primarily manifests through altered mental status, rather than respiratory issues. *II, III and IV* - This option is incorrect as it includes **Apnoea** and omits **Alertness**, which is a fundamental component of the **4AT delirium screening tool**. - **Alertness** is crucial for evaluating the patient's level of consciousness, a primary sign of delirium.
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