Delirium Flashcards
causes of confusion
pain constipation dehydration poor sleep recent surgery medications - can cause electrolyte imbalances, constipation, dehydration infection alcohol withdrawal electrolyte imbalance
subdural haematoma or intracranial bleed may cause confusion but would be associated with a focal deficit
TIA/ stroke usually cause neurological deficits where confusion is a global cognitive deficit
brain tumour - specific neurological deficits
diagnosis of confusion/cognitive impairment
AMTS: most appropriate for a quick cognitive assessment
MOCA and MMSE: good sensitivity and specificity but quite time consuming
4AT
diagnosis of delirium
CAM assessment - positive = delirium
must have features in both 1 and 2 and a feature from 3 or 4
1) acute onset and fluctuating course
2) inattention - counting backwards or reduced attention during review
3) disorganised thinking (incoherent disorganised speech)
4) altered level of consciousness (hyper-alert, hypo-alert, or both)
if unsure if patient has delirium or dementia, manage for delirium initially until proven otherwise
management of delirium
treat underlying cause reassurance and reorientation in as calm environment as possible promote normal sleeping pattern increased nurse observation increased oral intake of food and fluids regular monitoring of AMTS
alcohol intake can cause delirium - treat withdrawal with oral benzodiazepines and chlordiazepoxide
if a patient with delirium becomes agitate, management:
calmly talk to them reassure re-orinetate one to one nursing supervision comfort and use eye contact conservative measures should be used initially and are usually effective
if agitated and at risk of harming themselves or others give medication
short term usually one week or less and started at lowest possible dose and titrated cautiously to effect
haloperidol 0.5mg orally or 1mg IM (contraindicated in PD or dementia with lower bodies - consider lorazepam)
OR
olanzapine
if delirium doesn’t resolve after treatment
re-evaluate for underlying causes
follow up and assess for possible dementia
definition of delirium
acute onset of disturbed consciousness, cognitive function or perception with a fluctuating course
usually develops quickly over the space of a couple of Days
RF for delirium
age
dementia
frailty
sensory impairment
hyper and hypoactive delirium
hyperactive: restlessness, agitation, heightened arousal and aggression
hypoactive: drowsiness, increased sleeping, quiet or withdrawn behaviour. More difficult to identify, increased mortality
prognosis of delirium
when causes are found and treated: 2/3 will recover (1/3 quickly, 1/3 slowly) but 1/3 don’t completely recover, often associate with admission to a care home or death
associated with
longer hospital staying
increased incidence of dementia
increased complications such as falls and pressure ulcers
increased rate of admission to long term care
more likely to die
prevention of delirium
lighting and clear signage
a clock and calendar
reorientate patient - explain where they are, who they are, what your role is
cognitive stimulating activities
regular visits from family and friends
encourage oral fluid intake - if needed IV
assess for hypoxia and optimise o2 saturation if necessary
encourage mobilisation and walking
look for and treat infection
avoid catheterisation
medication reviews
assess and manage pain
follow advice on nutrition
resolve and reversible causes of sensory impairment e..g impacted wax
ensure hearing aids and visual aids are wokring
schedule medication rounds to avoid disturbing sleep
reduce noise to a minimum during sleep periods
