Delirium Flashcards
What are the key features of delirium?
- Disturbed consciousness (essential for delirium diagnosis)- can be hypoactive/hyperactive or a mix of both
- Change in cognition
- Acute onset and fluctuant
What are other common, but not key, features of delirium?
- Disturbance of sleep wake cycle
- Disturbed psychomotor behaviour
- Emotional disturbance
When is delirium most common?
At the extremes of age
Name some factors that can precipitate delirium
- Infection (but not always a UTI!)
- Dehydration
- Biochemical disturbance
- Pain
- Drugs
- Constipation/Urinary retention
- Hypoxia
- Alcohol/drug withdrawal
- Sleep disturbance
- Brain injury (stroke/tumour/bleed etc)
- Changes in environment/emotional distress
- Sometimes no idea and often multiple triggers
What percentage of patients are affected by delirium?
20-30% of in-patients
50% of people post-operatively
85% of patients at the end of life
What are the possible complications of delirium?
- Increased morbidity and mortality
- Longer length of stay in hospital
- Increased rate of institutionalisation
- Persistent functional decline
How is delirium diagnosed?
Using the 4AT screening tool
What are the component parts of the 4AT screening tool?
Alertness
AMT4
Attention
Acute change or fluctuating course
How is alertness assessed on a 4AT?
Ask patient to state name and address
If normal, 0 points
If sleepy <10s after waking, 0 points
If clearly abnormal, 4 points
How is AMT4 assess on a 4AT?
Ask the patient their location, age, their date of birth and the current year
No mistakes- 0 points
1 mistake- 1 point
2 or more mistakes- 2 points
How is attention assessed on a 4AT?
Ask patient to state months of the year in reverse order
Achieves 7 or more months correctly- 0 points
Starts but achieves <7 months/refuses to start- 1 point
Untestable- 2 points
How is acute change assessed on a 4AT?
Establish whether there is evidence of fluctuation or change in mental function over the previous fortnight that is still present in the last 24 hours
No- 0 points
Yes- 4 points
How is a 4AT score interpreted?
4 or above- possible delirium +/- cognitive impairment
1-3- possible cognitive impairment
0- delirium or cognitive impairment unlikely
What initial steps should be taken when delirium is diagnosed?
Full history and examination to establish the cause
Care should also be taking when giving the diagnosis to distinguish delirium from dementia and highlight that delirium usually settles down
Blood tests and ECGs can also be done to establish a cause
What is the non-pharmacological management of delirium?
- Re-orientate/reassure agitated patients (family/carers usually better at this)
- Encourage early mobility and self-care
- Correction of sensory impairment
- Normalise sleep-wake cycle
- Ensure continuity of care
- Avoid urinary catheters/venflons
- Try and avoid admissions and discharge ASAP
