Delirium Flashcards
(22 cards)
What is delirium?
Delirium is an acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma, or drugs.
Main features of delirium?
Disturbance in attention
Change in cognition
(eg, memory deficit, disorientation, language disturbance, perceptual disturbance)
Delirium develops over a long period of time. True/false?
False
Develops over a short period (usually hours to days) and tends to fluctuate during the day.
Delirium is a serious medical condition associated with increased levels of morbidity and mortality. True/false?
True
What is the % prevalence of delirium in acute adult general med wards?
20% prevalence
What are the risk factors for delirium?
Elderly
Pre-existing cognitive impairment
Post-operative
Sensory impairment e.g. deaf/blind
Previous history of delirium
Drug/alcohol dependence
Depression
Polypharmacy
Multiple co-morbidities (e.g. frailty, Parkinson’s, cerebrovascular disease)
Critical care admission e.g. HDU/ITU
What are the causes of delirium using the DELIRIUM mnemonic?
Drugs/medication
Electrolyte disturbance e/g/ hyponatraemia
Lack of drugs (withdrawal)
Infection
Reduced sensory input, pain
Intracranial e.g. stroke/subdural
Urinary retention/constipation
Metabolic e.g. acute kidney injury, hypoglycaemia, B12/folate
Overall features of delirium?
Acute onset
Fluctuating course
Altered conscious level (may be hypo/hyperactive)
Inattention/decreased awareness
Disorganised thinking (may include psychotic features e.g. hallucinations, severe agitation)
What are the 2 main subtypes of delirium?
Hyperactive and hypoactive
Features of hypoactive delirium?
Withdrawn, apathetic, sleepy, coma
Features of hyperactive delirium?
Agitated, aggressive, wandering
Why does hypoactive delirium have a poorer prognosis?
Compared to hyperactive prognosis, hypoactive delirium is harder to spot and diagnose.
A change in mood or personality is a notable feature of delirium. Some patients can display “sundowning”, what is this?
Sundowning is agitation and confusion worsening in the late afternoon and evening
What is the screening tool used in the case of a possible delirium diagnosis?
4-AT score
Components of the 4-AT score?
Alertness - drowsy or sleepy during assessment. Rated based on normal, slightly sleepy (for <10 seconds after waking then return to normal) and abnormal.
AMT4 - age, date, place (name of hospital or building), current year. 1 point awarded for each mistake up to 2.
Attention - can recite months of the year backwards. 7 or more seen as adequate.
Acute change or fluctuating course
The higher the score on the 4-AT, the higher the chance of delirium as a diagnosis. True/false?
True
Apart from the 4-AT score, what other investigations can be done for delirium?
Bedside - bladder scan, review medications, ECG (arrhythmias, ischaemic changes that could cause hypoperfusion) urine MC&S - you should not perform urine dipstick if >65 as they are less sensitive in this age group.
Bloods: FBC, urea and electrolyes, liver function tests, thyroid function tests, and blood cultures.
Imaging: chest X-ray, or ultrasound of the abdomen. Neuroimaging with CT or MRI head is reserved for those without a clear identifiable cause.
Management of delirium?
Primarily focused on treating underlying cause.
Particularly using non-pharmacological management as first line including:
Providing an environment with good lighting
Maintaining a regular sleep-wake cycle
Regular orientation and reassurance
Ensuring the patient’s glasses and hearing aids are used if needed
In the management of delirium, what therapy type is used first line?
Non-pharmacological therapy is used first line in the management of delirium
For patients who are extremely agitated and potentially a danger to themselves or others, what pharmacological interventions may be used?
Small doses of haloperidol or lorazepam.
Olanzapine may also be considered however, these should be used with caution, especially in the elderly, due to the risk of side effects.
What is a considerable risk for delirium?
Polypharmacy (patient being on multiple medications at one time)
List of medications that could potentially lead to delirium?
Opioids – tramadol, MST, oramorph, codeine etc
Anticholinergics – amitriptyline, oxybutynin, solifenacin etc
Sedatives – benzos, sleeping tablets, anti-histamines (includes ranitidine!)
Psychotropic medications – lithium, anti-psychotics, anti-depressants (SSRIs)
Anti-epileptics – phenytoin, phenobarbital, carbamezapine
Cardiac medications – digoxin, anti-hypertensives
Steroids, NSAIDs
Anaesthetic agents
Withdrawal of medications/alcohol/nicotine
Parkinson medications – although NEVER stop these acutely without d/w PD specialist
