Delirium Flashcards

1
Q

What are the risk factors for delirium?

A
Dementia 
Multiple comorbidities
Physical frailty 
Older age 
Sensory impairments
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2
Q

What are the first line investigations?

A
WCC/ CRP 
Electrolytes 
LFTs
Glucose 
Thyroid function tests 
Chest x-ray 
Urinalysis 
ECG
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3
Q

What are the second line investigations?

A
Serum calcium, B12, folate
Arterial blood gas (hypoxia, acidosis) 
Specimen cultures (blood, sputum) 
CT/MRI head
Electroencephalogram 
Toxicology screen 
Bladder scan (urinary retention)  
Lumbar puncture
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4
Q

What are the precipitating factors?

A
drug initiation 
medical illness
systemic infection 
metabolic derangement 
surgery 
pain 
brain disorders
systemic organ failure
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5
Q

Important ddx of delirium?

A

Dementia

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6
Q

What are the key features of delirium?

A
Acute onset 
Fluctuating course
Disorganised thinking 
Altered level of consiousness 
Inattention and distractibility 
Underlying medical cause (usually)
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7
Q

What is the presentation of delirium?

A

an acute disorder associated with medical illness, medications etc.

Impaired cognition associated with an affective disorder or psychosis

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8
Q

What is the onset and duration of delirium?

A

Acute onset

Lasts days/weeks

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9
Q

What is the first step in managing delirium?

A

treat underlying cause

examples

  • polypharacy –> drug review
  • pain –> analgesia
  • constipation –> laxatives
  • infection –> abx
  • correct electrolytes
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10
Q

What is the second step in managing delirium?

A
involve family 
soft lighting 
clocks and calendars 
sleep hygiene/ promote night time sleeping
correct sensory impairment 
keep mobile and active 
avoid multiple room/ward moves 
minimise provocation (noise, restraints)
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11
Q

What should be monitored in delirium?

A
Vital signs 
Bowels 
Nutrition and hydration 
Pressure areas
Electrolytes 
Response to antibiotics
Re-explore diagnosis if not improving
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12
Q

What is the prevalence of delirium?

A

30% of older hospitalised medical patients

10-15% of surgical patients

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13
Q

How is the diagnosis of delirium made?

A

AMT on admission to screen - <8/10 should lead to more detailed evaluation

The confusion assessment method is sensitive and specific for delirium - following criteria:

acute onset and fluctuating course AND
inattention AND
disorganised thinking OR altered level of consciousness

Delirium may be hyperactive, hypoactive or mixed

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14
Q

What is the ABC approach to managing delirium?

A

Antecedents - that trigger difficult behaviours in the context of the delirium

Behaviours - what is the patient trying to achieve? Can you help them achieve it safely?

Consequences - of the the behaviour - is it causing any harm? What is the harm?

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15
Q

Should drugs be used in management?

A

Drugs should be avoided and only used if other interventions have been tried and failed

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16
Q

Which drugs should be used?

A

Haloperidol and lorazepam - orally or IM

17
Q

Which drug is preferred in parkinson’s disease or levy body dementia and why?

A

Lorazepam is preferred due to the extrapyramidal SEs of haloperidol

18
Q

What are the two indications for use of sedative drugs?

A
  • Rapid tranquillisation of an agitated patient where there is immediate risk of harm or danger
  • Short term control of distress
19
Q

What does should the drugs be used at?

A

The lowest possible effective dose

20
Q

How does delirium effect capacity?

A
  • It impairs capacity
  • Decisions should be delayed until after delirium resolves
  • if decision cannot wait then treatment decisions should be made in the patients best interests
21
Q

What is the prognosis for a patient with delirium?

Percentage which persist at 2 weeks/1 month/never recover

A

40% persist at 2 weeks

33% persist at 1 month

20% never recover

some patients (particularly with dementia) will not reach their pre-delirium level of function

22
Q

What are the consequences of delirium?

A

Increased mortality - 60% more likely at one year

Prolonged hospital admission

Higher rate of institutionalisation

An eightfold increased risk of going on to develop dementia within 3 years