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Older Adult Exam 1 > Delirium > Flashcards

Delirium Flashcards

1
Q

what is delirium?

A
  • 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
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2
Q

what are some non-diagnostic terms describing delirium?

A
  • senility
  • dementia
  • change in mental status
  • acute confusional state
  • sundowning
  • disoriented
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3
Q

what are some adverse outcomes of delirium?

A
  • higher rates of readmission
  • higher rates of institutionalization
  • higher mortality
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4
Q

what is the physiology of delirium?

A
  • oxygen deprivation
  • physiologic stress
  • neurotransmitter hypothesis: reduced cholinergic function, increased dopamine
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5
Q

what are some PREDISPOSING factors for developing delirium?

A
  • dementia
  • previous episodes of delirium
  • functional impairment
  • sensory impairment
  • major organ system/comorbidity
  • depression
  • hx TIA/CVA
  • ETOH misuse
  • older age (>75yo)
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6
Q

what are some PRECIPITATING factors for developing delirium?

A
  • drugs
  • polypharmacy
  • use of physical restrains
  • use of bladder catheter
  • electrolyte imbalance
  • infection
  • surgery
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7
Q

what are the DSM V criteria for diagnosing delirium?

A
  • disturbance in attention and awareness
  • acute onset and fluctuating course
  • change in cognition
  • evidence of underlying medical condition, or from medication or drug withdrawal
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8
Q

what are the 3 clinical subtypes of delirium?

A
  • hyperactive
  • hypoactive
  • mixed
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9
Q

how does hyperactive delirium present?

A

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

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10
Q

how does hypoactive delirium present?

A
  • lethargy
  • slowed speech
  • decreased alertness
  • apathy
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11
Q

how does mixed delirium present?

A

shift btwn hyper- and hypoactive states

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12
Q

what are some symptoms to look for when assessing delirium?

A
  • 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-)
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13
Q

what does the person with delirium experience?

A
  • inability to interpret internal and external stimuli
  • inability to formulate an effective response to negative stimuli
  • inability to communicate needs
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14
Q

what are some differential diagnoses for delirium?

A
  • dementia
  • depression (41% misdiagnosed as depression)
  • other psychiatric disorders
  • CNS pathology
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15
Q

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

A
  • clinical history
  • physical examination
  • lab studies
  • engaging IDT
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16
Q

what is the difference in onset between delirium and dementia?

A
  • delirium: rapid onset

- dementia: insidious onset

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17
Q

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

A
  • delirium: primary deficit in attention

- dementia: primary deficit in short term memory

18
Q

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

A
  • delirium: fluctuates during the day

- dementia: does not fluctuate during the day

19
Q

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

A
  • delirium: visual hallucinations common

- dementia: visual hallucinations less common

20
Q

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

A
  • delirium: cannot attend to MMSE

- dementia: can attend to MMSE, but do poorly

21
Q

how do you recognize delirium superimposed on dementia?

A

difficult to recognize

sx not consistent w/ dementia:

  • acuteness
  • fluctuation
  • inattention
  • altered LOC
22
Q

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

A

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
23
Q

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

A
  • VS
  • pulmonary
  • cardiac
  • GI (including suprapubic and rectal)
  • neurologic
  • Mental status exam
24
Q

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

A
  • alertness (alert, hyperalert, hypoalert)
  • behavior
  • mood
  • affect
  • verbalizations
  • motor abilities
25
Q

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

A
  • CBC
  • UA
  • electrolytes
  • BUN, creatine
  • glucose
  • albumin
  • LFTs
  • TSH
  • ECG + radiographs
  • EEG
26
Q

what is the hallmark diagnostic evaluation of delirium?

A

abnormal mental status exam

27
Q

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

A

confusion assessment method (CAM)

28
Q

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

A
  • 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
29
Q

how is the CAM scored?

A

positive for delirium if 3/4 features present

30
Q

what are some ways to prevent delirium?

A

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
31
Q

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

A
  • 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
32
Q

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

A
  • 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
33
Q

when should pharmacological interventions be used?

A
  • 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
34
Q

what are some cautions with pharmacologic interventions for delirium?

A
  • 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
35
Q

what is first line pharmacologic therapy for delirium?

A

low doses of neuroleptics

36
Q

which neuroleptics may be better tolerated in older patients?

A

newer antipsychotics like olanzapine and quetiapine, rather than typical antipsychotics

37
Q

what are the most common side effects of antipsychotic medications?

A

extrapyramidal symptoms (EPS)

  • dystonic rxns
  • akathisia
  • tardive dyskinesia
38
Q

what medications are recommended with ETOH withdrawal?

A

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

39
Q

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

A

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
40
Q

what is some delirium aftercare we can perform?

A
  • 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

Older Adult Exam 1 (7 decks)

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