Delirium

Question 1

what is delirium?

Answer 1

• a geriatric emergency
• an acute decline in cognitive functioning
• usually in response to a noxious insult
• fluctuating syndrome of altered attention, awareness, and cognitive disturbances

Question 2

what are some non-diagnostic terms describing delirium?

Answer 2

• senility
• dementia
• change in mental status
• acute confusional state
• sundowning
• disoriented

Question 3

what are some adverse outcomes of delirium?

Answer 3

• higher rates of readmission
• higher rates of institutionalization
• higher mortality

Question 4

what is the physiology of delirium?

Answer 4

• oxygen deprivation
• physiologic stress
• neurotransmitter hypothesis: reduced cholinergic function, increased dopamine

Question 5

what are some PREDISPOSING factors for developing delirium?

Answer 5

• dementia
• previous episodes of delirium
• functional impairment
• sensory impairment
• major organ system/comorbidity
• depression
• hx TIA/CVA
• ETOH misuse
• older age (>75yo)

Question 6

what are some PRECIPITATING factors for developing delirium?

Answer 6

• drugs
• polypharmacy
• use of physical restrains
• use of bladder catheter
• electrolyte imbalance
• infection
• surgery

Question 7

what are the DSM V criteria for diagnosing delirium?

Answer 7

• disturbance in attention and awareness
• acute onset and fluctuating course
• change in cognition
• evidence of underlying medical condition, or from medication or drug withdrawal

Question 8

what are the 3 clinical subtypes of delirium?

Answer 8

• hyperactive
• hypoactive
• mixed

Question 9

how does hyperactive delirium present?

Answer 9

increased psychomotor activity, such as rapid speech, irritability, and restlessness

Question 10

how does hypoactive delirium present?

Answer 10

• lethargy
• slowed speech
• decreased alertness
• apathy

Question 11

how does mixed delirium present?

Answer 11

shift btwn hyper- and hypoactive states

Question 12

what are some symptoms to look for when assessing delirium?

Answer 12

• attentional deficits
• disorganized thinking (altered thought content and thought process)
• disturbance of perception (hallucinations, illusions, delusions)
• disturbed sleep-wake cycle
• psychomotor activity (hyper- and hypo-)

Question 13

what does the person with delirium experience?

Answer 13

• inability to interpret internal and external stimuli
• inability to formulate an effective response to negative stimuli
• inability to communicate needs

Question 14

what are some differential diagnoses for delirium?

Answer 14

• dementia
• depression (41% misdiagnosed as depression)
• other psychiatric disorders
• CNS pathology

Question 15

what are some ways to differentiate delirium from other causes of confusion?

Answer 15

• clinical history
• physical examination
• lab studies
• engaging IDT

Question 16

what is the difference in onset between delirium and dementia?

Answer 16

• delirium: rapid onset

- dementia: insidious onset

Question 17

what is the difference in primary deficit between delirium and dementia?

Answer 17

• delirium: primary deficit in attention

- dementia: primary deficit in short term memory

Question 18

what is the difference in fluctuation of disease course between delirium and dementia?

Answer 18

• delirium: fluctuates during the day

- dementia: does not fluctuate during the day

Question 19

what is the difference in commonality of visual hallucinations between delirium and dementia?

Answer 19

• delirium: visual hallucinations common

- dementia: visual hallucinations less common

Question 20

what is the difference in performance on the MMSE between delirium and dementia?

Answer 20

• delirium: cannot attend to MMSE

- dementia: can attend to MMSE, but do poorly

Question 21

how do you recognize delirium superimposed on dementia?

Answer 21

difficult to recognize

sx not consistent w/ dementia:

• acuteness
• fluctuation
• inattention
• altered LOC

Question 22

what are some assessment questions to ask when assessing for delirium?

Answer 22

question family members and caretakers…

• when it began
• does the condition change throughout the day
• change in sleep patterns
• thought problems
• hx mental illness/cognitive impairment
• sudden decline/change in physical health/function
• new Rx or OTC meds

Question 23

what are some critical PE components to rule out or identify causes?

Answer 23

• VS
• pulmonary
• cardiac
• GI (including suprapubic and rectal)
• neurologic
• Mental status exam

Question 24

what are some specific factors to assess for in psych/neuro exams?

Answer 24

• alertness (alert, hyperalert, hypoalert)
• behavior
• mood
• affect
• verbalizations
• motor abilities

Question 25

what are some potential lab studies to collect based on history and physical?

Answer 25

- CBC - UA - electrolytes - BUN, creatine - glucose - albumin - LFTs - TSH - ECG + radiographs - EEG

Question 26

what is the hallmark diagnostic evaluation of delirium?

Answer 26

abnormal mental status exam

Question 27

what mental status exam is most commonly used to diagnose delirium?

Answer 27

confusion assessment method (CAM)

Question 28

what are some benefits of using CAM to assess for an diagnose delirium?

Answer 28

- quick and accurate - based on DSM criteria - basedo n observations of cardinal elements of delirium, i.e. acute onset/fluctuating course AND inattention; altered LOC OR disorganized thinking

Question 29

how is the CAM scored?

Answer 29

positive for delirium if 3/4 features present

Question 30

what are some ways to prevent delirium?

Answer 30

sound geriatric care - recognize risk factors - rapid tx of underlying causes - "prehabilitation" - immunizations for influenza and pneumococcal PNA - early tx of illness to prevent hospitalization - creation of a maximum supportive environment - deliriogenic meds d/c'd or reduced - community support systems - address stressful situations - family/friends help detect delirium in early stages

Question 31

what are some ways to promote a supportive environment for those at risk for delirium?

Answer 31

- presence/ability to contact family members, friends, or others PRN - presence of a relative on admission - familiar items from home - minimize sensory losses that contribute to misperceptions - pain mgmt - night-light; minimal noise - facilitate nighttime sleep by consolidating tx, rescheduling meds, and unit-wide noise reduction strategies

Question 32

what are some additional non-pharm strategies for preventing delirium?

Answer 32

- avoid or minimize physical restraints - effective communication aimed at reorienting the patient to surroundings ~large, easily visible clock wand calendar ~board w/ names of care team members ~daily schedule ~integration of orienting cues into pt's daily routine

Question 33

when should pharmacological interventions be used?

Answer 33

- when behaviors associated w/ psychotic thinking and perceptual disturbances (i.e. hallucinations) pose a safety risk - when delirium interferes with needed medical therapies - when behavioral interventions fail

Question 34

what are some cautions with pharmacologic interventions for delirium?

Answer 34

- meds shouldn't be substituted for detection, correction, or elimination of the underlying cause or causes of delirium - sensitivities to anticholinergic side effects of antipsychotic drugs may worsen delirium - low doses over shortest possible time period

Question 35

what is first line pharmacologic therapy for delirium?

Answer 35

low doses of neuroleptics

Question 36

which neuroleptics may be better tolerated in older patients?

Answer 36

newer antipsychotics like olanzapine and quetiapine, rather than typical antipsychotics

Question 37

what are the most common side effects of antipsychotic medications?

Answer 37

extrapyramidal symptoms (EPS) - dystonic rxns - akathisia - tardive dyskinesia

Question 38

what medications are recommended with ETOH withdrawal?

Answer 38

benzodiazepines - in non-ETOH withdrawal, benzos may worsen delirium

Question 39

what are the 3 main medications given to those with delirium (and dosages)? what SEs should we consider?

Answer 39

haldol: - 0.5-1mg daily, may also use IM - watch EPS olanzapine/quetiapine: - 2.5-5mg daily (zyprexa) or 25mg BID (seroquel) - fewer SEs - better tolerated lorazepam - 0.5-1mg q4hr; may use IM or IV - can cause more confusion in older adults - good for ETOH withdrawal

Question 40

what is some delirium aftercare we can perform?

Answer 40

- help pt and family understand the experience - f/u psych care PRN - instruct pt and family to inform health care providers or prior episodes of delirium and suspected etiology