Delirium Flashcards
(20 cards)
Define delirium?
- Disturbance in attention
- Change in cognition, e.g: memory deficity, disorientation, language disturbance, perceptual disturbance
- Develops over a SHORT PERIOD (usually hours-days) and tends to FLUCTUATE during the day
Distinguishing between delirium and dementia?
Delirium develops over a short period of time, unlike dementia
Causes of delirium?
Always MULTI-FACTORIAL
Direct physiologic consequences of:
- A general medical condition, e.g: infection, MI, electrolyte imbalance,
- Intoxicating substances
- Medications
- Multi-factorial
It often represents an atypical presentation of an acute medical illness, e.g: MI in an older patient
Consqeuences of delirium?
Prolonged hospital stay and thus more hospital-acquired complications, e.g: falls and pressure sores
Increased mortality
Increased incidence of subsequent dementia; in fact, dementia itself increases the risk of delirium, due to the initial lower level of cognition, creating a cycle
Types of delirium?
Hyperactive delirium (easier to diagnose) - wandering, agitated and restless patients
Hypoactive delirium - withdrawn, apathetic, sleepy and slow patients, who are often missed; this has higher mortality
Hypoactive delirium is most common but it can also be mixed
Differences in the features of dementia, delirium and depression?
Pathophysiology of delirium?
Poorly understood; there is variable derangement of multiple neurotransmitters, part. ACh
Clear factors are direct toxic insults to the brain, e.g: drugs, hypoxia, low Na+ and low glucose
Other potential factors include aberrant stress responses, e.g: cortisol (hospital is a stressful environment), PGs, cytokines, serum cholinesterase
What is a common misdiagnosis when an older patient is confused?
UTI (confusion does not automatically mean this)
Steps in developing delirium?
Often a patient who has predisposing factors, and is at risk of delirium, is exposed to precipitating factors and develops delirium
Precipitating factors for delirium?
Drugs and intoxicating substances, e.g: alcohol
General medical issues, e.g: infections (pneumonia, UTI, etc) hypoxia, constipation, MI, urinary retention
Electrolyte imbalance, glucose issues
Being in an unfamiliar environment
Pain and irriation, e.g: fractured hip, urinary catheterisation
Fever (may also cause delirium in children)
• Dehydration
4 hallmarks of delirium?
- Acute and fluctuating
- Inattention
- Altered level of consciousness
- Disorganised thinking
Diagnostic tool for delirium?
CAM
4AT scoring system
What do the 4AT scores mean?
4/above = possible delirium +/- cognitive impairment
1-3 = possible cognitive impairment
0 = delirium or severe cognitive impairment unlikely but delirium is still possible if the info under 4. is incomplete
Describe the Confusion Assessment Method (CAM) for the diagnosis of delirium
- Acute change in mental status and fluctuating mental status over the course of the day
AND
- Inattention - use backward months test or digit span test (<7 is abnormal)
AND
- Disorganised thinking, e.g: rambling
OR
- Altered LoC, i.e: hyperalert/irritable OR drowsy/sleepy
Management of delirium?
Identify and correct all underlying causes:
- Check bloods, correct electrolytes and glucose
- Check for and correct hypoxia
- Ensure good hydration
- Stop drugs with neurotoxic effects
- Relieve pain (beware of too much opioid)
- Treat constipation
- Septic screen
- ECG (rule out MI/arrhythmia)
- Avoid a urinary catheter, unless in retention
- Consider alcohol withdrawal
When are pharmacological measures used?
When all non-pharmacological measures fail and the patient is a risk to themselves or others:
• Use 0.5mg halperidol orally
Why are benzodiazepines, e.g: Lorezapam, avoided in delirious patients? Exceptions?
Tend to worsen delirium
Only use if alcohol withdrawal or if patient has a seizure; Lorazepam should be used
When is Quetiapine used?
25mg orally for patients with Parkinson’s disease/Lewy Body Dementia
Environmental and general measures?
Continuity of staff in a quiet, calm environment (side-room nursing)
Low night lighting
Visible clocks and calendars
Correct sensory deficits, e.g: glasses, hearing aids, treat ear wax
Attempt restoration of normal sleep patterns (delirious patients often sleep during the day and stay awake all night, with the darkness stressing them further)
Why should delirium be followed-up?
Many patients suffer from PTSD or develop dementia later on
However, the initial delirium must settle before a diagnosis of dementia can be made; NOTE: some patients can have chronic delirium, so a diagnosis of dementia should be made afterwards
