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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The fourth edition of The Diagnostic and Statistical Manual of Mental Disorders defines delirium as "a reversible state of confusion with a reduced level of consciousness manifest as an inability to focus, sustain or shift attention." Pharmacologic agents are important contributors to delirium in hospitalized elderly patients and those patients in the perioperative state. Delirium is especially problematic in patients who are given multiple agents, including hypnotics and analgesics. With an appropriate history, physical examination, and investigations, the causes of delirium can be categorized and are usually due to drug intoxication, metabolic disorders, infection, cardiac disorders, stroke, trauma, reactions to pain, or isolation.
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PMID:Management of dementia and acute confusional states in the perioperative period. 1506 20

We report a 53-year-old male patient with late onset mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes(MELAS) with hallucination and delusion. The patient manifested various neurological symptoms including perceptive deafness, muscle weakness of limbs with loss of consciousness, sensory abnormalities in hands, feet and a face, abnormal sense of taste, tremor, palsy of upward eye movement and weak deep tendon reflexes prior to the psychotic episode. He was diagnosed as MELAS, because of high serum lactic acid and pyruvic acid, and the point mutation in the mitochondrial DNA 3243. SPECT imaging showed decreased perfusion in occipital cortex and thalamus. These SPECT changes improved after disappearing visual hallucination. Hallucination might be caused by delirium due to stroke-like episode. Dysfunction in the occipital cortex and thalamus might be involved with this perfusion change.
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PMID:[A case with late-onset MELAS with hallucination and delusion]. 1523 27

Perioperative management of geriatric patients is becoming an important component in anaesthetic practice in the 21st century. This phenomenon is due to the fact that people aged 65 and over are the segment with the fastest growing population. Thus, it is estimated that by the year 2025 20 % of the population in the western hemisphere will be > 65 years of age. Currently, elderly patients comprise one-third of all operations, and one out of two patients older than 65 years of age will undergo an operation in their lifetime. The dramatic change in demographics of surgical patients will have a tremendous impact on the use of anaesthetics. Older patients facing surgery can generally be expected to be a more complex case than their younger counterparts. They have more systemic diseases (e. g. cardiac, pulmonary, endocrine), and usually these diseases have advanced to more serious stages. These patients may suffer disability, both physical and mental, and may show differences in the pharmacokinetic as well as the pharmacodynamic of compounds such as opioids. While neuronal numbers, dendrites and synapses decline with age and the ventricular volume triples, cerebral circulation is similar to young adults, although there is a reduction in cerebral blood flow (CBF). This is because of the lower unit weight, lower CBF and CMRO (2), which are tightly coupled in aging where autoregulation is preserved. However, because of a decline in dopaminergic, serotonergic, cholinergic and GABAergic transmitters, anticholinergic compounds (atropine, scopolamine) as well as some anaesthetics such as ketamine, benzodiazepines or even propofol may produce delirium and/or an increase in efficacy when given together with opioids. Therefore it is mandatory to consider a pharmacologic interaction with a potentiation and/or an addition in effects of other drugs when judging the net action of opioids in the elderly. Physicians and nurses treating geriatric patients tend to have an unfounded level of fear of complications associated with treating perioperative pain. Although it is known that inadequate analgesia may delay recovery, the treatment of perioperative pain in the geriatric patient remains inadequate, even relative to younger patients. It is well established that there is increased responsiveness to the effects of opioids in the elderly. This may result in an increased risk of respiratory depression, while especially the elderly female patient demonstrates an increase in the duration of effects, but the risk of nausea is not augmented. Increased sensitivity of older patients to systemic opioids mostly involves pharmacokinetic factors such as a higher proportion of unbound and active substances as well as changes in drug redistribution. Because of a 40 % reduction in stroke volume in the elderly, there is a protracted redistribution of opioids to the liver. This results in a prolonged metabolisation, a lesser inactivation over time followed by an increase in duration of effects, mainly impairment of respiration. To a much lesser extent, pharmacodynamic factors with an increased response at opioid receptor sites have to be considered. Although the mechanisms causing differences of opioid action in the elderly may be complex, the clinical implications are not. They include slow titration of opioids to allow for long circulation times, lower total doses because of increased sensitivity, and anticipation of a longer duration of action because of reduced clearance. Since elderly patients present multimorbidity, therapy of chronic pain has to be considered in the light of multidrug intake, which, due to interaction, results in marked side-effects, and a prolonged duration of action. Those opioids should be used which, due to their pharmacokinetic properties, have a reduced volume of distribution, present a low plasma protein binding and finally result in the formation of no pharmacologically active metabolites.
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PMID:[Use of opioids in the elderly -- pharmacokinetic and pharmacodynamic considerations]. 1533 29

The pathogenesis of delirium in acute stroke is incompletely understood. The use of medications with anticholinergic (ACH) activity is associated with an increased frequency of delirium. We hypothesized that the intake of medications with ACH activity is associated with delirium in acute stroke patients. Delirium was assessed using the DSM-IV-TR criteria and the Delirium Rating Scale, in a sample of consecutive patients with an acute (< or =4 days) cerebral infarct or intracerebral haemorrhage (ICH). We performed a gender and age matched case-control study. Twenty-two delirious stroke patients (cases) and 52 non-delirious patients (controls) were compared concerning the intake of ACH medications (i) before stroke, (ii) during hospitalization but before the assessment. The variables associated with delirium on bivariate analysis were entered in a stepwise logistic regression analysis. The final regression model (Nagelkerke R2 = 0.65) retained non-neuroleptics ACH medication during hospitalization (OR = 24.4; 95% CI = 2.18-250), medical complications (OR = 20.8; 95% CI = 3.46-125), ACH medication taken before stroke (OR = 17.5; 95% CI = 1.00-333.3) and ICH (OR = 16.9; 95% CI = 2.73-100) as independent predictors of delirium. This preliminary result indicates that drugs with subtle ACH activity play a role in the pathogeneses of delirium in acute stroke. Medication with ACH activity should be avoided in acute stroke patients.
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PMID:Delirium in acute stroke: a preliminary study of the role of anticholinergic medications. 1546 55

Delirium or acute confusional status (ACS) is a common mental disorder found in hospitalized patients. A total of 278 patients were evaluated. Of these, 30 (10.8%) developed ACS. The patients who developed ACS were 70 years of age or older, had history of stroke or dementia, as well as impairment in activities of daily living, and required enteral feeding more frequently. The infections and hip fracture were the most frequent reasons for hospitalization. The mortality in patients with ACS was significantly higher than in patients without ACS.
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PMID:[Acute confusional state in hospitalized patients]. 1556 May 37

Factors influencing early hospital admission have been described for several stroke types but not for cerebral vein and dural sinus thrombosis (CVT). CVT is more difficult to diagnose than arterial stroke; delay in hospital admission may postpone CVT treatment. The purposes of this study were: (1) to describe the delay between the onset of symptoms and hospital admission of patients with CVT, and (2) to identify the variables that influence that delay. We registered the interval (days) between the onset of symptoms and hospital admission in 91 consecutive patients admitted to 20 Portuguese hospitals between June 1995 and June 1998. We also studied the impact of admission delay on treatments (prescription of anticoagulants and the number of days elapsed between the onset of symptoms and start of anticoagulation and admission). Median admission delay was 4 days. Twenty-two (25%) patients were admitted within 24 h. Two thirds of the patients were admitted within 7 days and 75% within 13 days. In multiple logistic regression analysis, admission within 24 h was positively associated with mental status disorder (delirium or abulia; OR = 4.59; 95% CI = 1.41-14.89) and negatively associated with headache (OR = 0.03; 95% CI = 0.00-0.32). Presentation as isolated intracranial hypertension was associated with admission delay of more than 4 days (OR = 2.63; 95% CI = 0.97-7.14). Papilloedema was associated with an admission delay of more than 13 days (OR = 4.69; 95% CI = 1.61-13.61). There was no association between admission delay and the proportion of anticoagulated patients. The interval between onset of symptoms and start of anticoagulation was shorter in patients admitted earlier (p = 0.0001, for either admission within 24 h, 4 or 13 days). There is a considerable delay until the clinical picture associated with CVT is recognised as justifying hospital admission, especially when patients present with symptoms identical to isolated intracranial hypertension syndrome.
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PMID:Delay in hospital admission of patients with cerebral vein and dural sinus thrombosis. 1564 27

While the Mini-Mental State Examination (MMSE) was originally developed to screen for dementia and delirium, many neurologists use this measure as a screening instrument for 'cognitive impairment' in hospitalized stroke patients. However, the validity of the MMSE as such has never been evaluated in acute stroke. We administered the MMSE in addition to a neuropsychological examination covering six cognitive domains to 34 stroke patients (mean interval between stroke and examination, 6.5+/-2.9 days) and 34 healthy controls. The area under the receiver operating characteristic curve (AUC) was calculated in addition to the sensitivity and specificity for various cut-off points on the MMSE. Seventy percent of the patients were impaired in at least one cognitive domain. The accuracy of the MMSE in detecting cognitive impairment was no better than chance (AUC = 0.67; p = 0.13). No optimum MMSE cut-off value could be identified. The MMSE is particularly insensitive to impairments in abstract reasoning, executive functioning, and visual perception/construction.
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PMID:Restrictions of the Mini-Mental State Examination in acute stroke. 1593 86

Carol's story is one of a disabled woman who, after living in her home for 10 years with the assistance of paid providers, is hospitalized in an acute care facility for surgery. Postoperative delirium and confusion cause Carol to lose decision-making capacity for a short time; even when her mental clarity returns, Carol is subject to disability bias, possibly unconscious, by health care providers who are persuaded to listen to her psychiatrically impaired son. The case study demonstrates that patients with disabilities in the acute care hospital environment need health care providers and ethics consultants who are open to learning their story and incorporate their wishes into a plan of care that supports their dignity.
Top Stroke Rehabil 2005
PMID:Stories of the silent: advocating for a disabled woman at end of life. 1611 Apr 31

A 62-year-old man presented with diminished consciousness, hypotension, hypoglycaemia and agitation. He had undergone heart surgery 1.5 weeks earlier. Due to a stroke as a postoperative complication, antihypertensive medication had been added. His lithium medication had been interrupted only on the first postoperative day. The presenting complaints were due to delirium as a result of lithium intoxication. The delirium faded away after interruption of the lithium medication and treatment with haloperidol and oxazepam. The patient and his family were informed as to the nature of the delirium and the precautions to be taken in case of any future disease or operation. Lithium should be discontinued preoperatively in all patients. If necessary, alternative psychiatric medication must be prescribed. After restarting lithium, the serum levels of lithium must be monitored.
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PMID:[Lithium use and perioperative management]. 1613 38

The psychopathology of stroke encompasses several psychiatric and behavioral disorders that have high prevalence in the geriatric population, reduce the patient autonomy and increase the caregiver's burden. These disorders are usually associated with other cognitive and neurological deficits, and are labelled as neuropsychiatric when the whole clinical picture is consistent with the specific dysfunction of a neural system or brain region. Thus the neuropsychiatry of stroke comprises disorders of the perception/identification of the self and the environment (anosognosia of hemiplegia, misidentification syndromes, confabulations, visual hallucinations, delirium and acute confusional state), amotivational syndromes (apathy and athymhormia), disorders of emotional reactivity (blunted affect, emotional incontinence, irritability, catastrophic reactions), poor impulse or ideation control (mania) and personality changes. The clinical profile of the subcortical vascular dementia also points to specific brain dysfunction (frontal-subcortical pathways) that manifests with behavioral (depression, emotionalism, irritability) and cognitive symptoms (psychomotor retardation, attention, executive and memory deficits). However, post-stroke depression and anxiety, which have a more variable clinical presentation and might be assimilated, for several aspects, to post-traumatic or adaptive disorders, are disorders less characterized in their neural correlates.
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PMID:[Psychopathology of stroke]. 1631 15


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