OP: Dementia + Delerium Flashcards
What is delirium?
Acute, transient and reversible state of confusion ( global disorder of cognition and consciousness). often due to other cause (infection, drugs, dehydration).
Onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.
What 2 states of delirium can you get?
HYPOactive
HYPERactive
what are clinical features of hypoactive delirium?
(often confused with depression)
Lethargy
withdrawn
Inattention
Slowness with everyday tasks
Excessive sleeping
what are clinical features of hyperactive delirium?
Agitation
Delusions
Hallucinations
Wandering
Aggression
Patients CAN fluctuate between hypoactive and hyperactive delirium - TRUE OR FALSE?
TRUE
Causes of delirium? CHIMPS PHONED
Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic / renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)
Assessing the confused patient:
in medical notes look for relevant past medical history such as…
Previous episodes of confusion
head injury
recent admission
stroke
atherosclerosis
Assessing the confused patient:
in medical notes look for current medications….
review drugs that may cause / contribute to confusion
e.g. opiates
anticholinergics
benzodiazepams
steroids
Antihistamines
antipsychotics
antidepressants
parkinson drugs
Assessing the confused patient:
in medical notes look for social Hx….
Home situation - carers / live alone
evidence of how coping
excess alcohol
excessive drug use
What bloods do you need to request for a confusion screen for your patient? And what looking for?
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g.
hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?
most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.
Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture
What questions does the Abbreviated Mental Test Score (AMTS) ask?
Ask the patient:
- “What is your age?”
- “What is the time to the nearest hour?”
- Give the patient an address, and ask them to repeat it at the end of the test (e.g. “42 West Street”)
- “What is the year?”
- “What is the name of this place?” or “What is your house number?”
- Can the patient recognise two persons (e.g. doctor, nurse)?
- “What is your date of birth?” (day and month sufficient)
- “In what year did World War 1 begin?”
- “Name the present monarch/prime minister/president”
- “Count backwards from 20 down to 1”
Each questions answered CORRECTLY. gets 1 point.
SCORE OF 6 or less suggests DEMENTIA ? DELIRIUM - further tests to confirm which
What would you look for in clinical examination of someone you are assessing for delirium?
Vital signs (e.g. fever in infection, low SpO2 in pneumonia)
Level of consciousness (e.g. GCS/AVPU)
Evidence of head trauma
Sources of infection (e.g. suprapubic tenderness in urinary tract infection)
Asterixis (e.g. uraemia/encephalopathy)
There is a patient with suspected delirium- you are asked to do a confusion screen.
What 3 categories of investigation does this involve?
Bloods
Urinanalysis
Imaging
What bloods do you need to request for a confusion screen for your patient? And what looking for?
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g.
hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?
most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.
Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture
What imaging do you need to do for a confusion screen for your patient? What looking for?
CT head- intracranial pathology (bleeding, ischaemic stroke, abscess)
Chest X-ray - pneumonia, pulmonary oedema
What is definitive management of delirium?
treat underlying cause
Supportive management of delirium?
- Pt has access to aids e.g. hearing aids/ glasses/ walking stick
- encourage independent activities e.g. washing / eating/ toileting
Environmental management of delirium?
- Access to clock and other orientation reminders
-familiar obects - photos/ wear own clothes
- involve family / regular carers
- ensure lighting and temperature optimal
Why must be very careful in treating an elderly patient for delirium when they have a background of Parkinsons / Lewy Body dementia?
Haloperidol 0.5 mg is the 1st-line sedative (oral preferred or IM if refused to take + immediate threat to others)
Parkinson’s disease- antipsychotics can worsen symptoms
1. Reduce Parkinson meds
2. if urgent treatment - use atypical antipsychotics e..g clozapine
What score can we use in a clinical setting to evaluate for frailty?
Rockwood clinical frailty score >65yrs
Some steps to prevent delirium?
avoid drugs that cause: opiates / benzodiazepines
asses factors that cause: pain control / drugs
Identify those at risk and monitor
use supportive and environmental management approaches for all patients
Define capacity
The ability to 1) understand, 2) retain, 3) weigh up information and 4) communicate a decision
When assessing capacity, what assumption should you start with?
Always start with the assumption that the patient DOES have capacity.
What steps are taken in assessing capacity?
- Maximise capacity - i.e. start from the presumption that patient has capacity to make decision. Offer audio/written information. Have family/friends present to help communicate. Discuss options in a way that they remember
Still unsure if pt has capacity? Move to step 2.
- Assess capacity - can they understand? Retain?
Weigh up info? Communicate decision?
If not - need advanced decisions as pt may lack capacity.
- Next - Is there an advance decision to refuse treatment (always present in England).? Has someone else been given legal authority to make decision?
If yes, that makes decision. If not, you make decision. - Reach agreement with team about treatment and care.
