11 - Delirium Flashcards

1
Q

What is delirium?

A

Disturbance in attention

Reduced awareness

Develops over a short period,

Fluctuate in severity throughout the day.

No pre-existing explanation

Is a direct consequence of a another medical condition.

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2
Q

What often happens to a P’s sleep-wake cycle in delirium?

A

It gets reversed

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3
Q

What cognition impairments are characteristic of delirium?

A

Hallucinations, disorientation and memory loss are characteristic of delirium

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4
Q

What are the subtypes of delirium?
Which is most common?

A

Hyperactive
Hypoactive
Mixed (most common)

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5
Q

Which subtype of delirium is associated with higher mortality?

Why?

A

Hypoactive - often mistaken for something else as less obvious and less distressing.

Worse outcome as associated with reduced oral intake, immobility with inc risk of pressure sores and hospital acquired infection.

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6
Q

What other diseases present similarly to hypoactive delirium?

A

Severe depression
Post-ictal phase
Non-convulsive status epileptics
Encephalitis

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7
Q

What other diseases present similar to hyperactive delirium?

A

Dementia
Psychosis

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8
Q

How can you tell the difference between delirium and dementia?

A
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9
Q

Why is diagnosis of delirium important?

A

Extremely common & associated with adverse outcomes

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10
Q

What percentage of patients with delirium still have symptoms at six months?

A

20%

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11
Q

What is solifenacin used for?

A

Treatment for overactive bladder - is an anti-cholinergic medication.

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12
Q

How is the PINCHME mnemonic used in delirium?

A

Identifies possible causes of delirium
- Pain
- Infection
- Nutrition
- Constipation
- Hydration
- Medication
- Environment

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13
Q

When thinking about the cause of delirium - what is it important to remember?

A

That any medical illness can precipitate delirium - not just geriatric illnesses.

AND

Most cases of delirium are multifactorial

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14
Q

What are the predisposing factors to delirium?

A

Older age
Dementia or cognitive impairment
Frailty

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15
Q

What are the precipitating factors of delirium?

A
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16
Q

How long after stopping alcohol does delirium tremens start?
What symptoms are seen?

A

3-10 days
Commonly associated with tactile hallucinations, formication
Can cause seizures and is potentially life threatening

17
Q

How is severity of stressor linked to delirium?

A

The severity of the stressor needed to cause delirium decreases with frailty, worsening cognition and age. The younger the patient, the more severe illness needed to develop delirium.

18
Q

What is the neurotransmitter hypothesis of delirium?

A

That alterations in NT production / function are part of the cause of delirium!
- inc dec ACh
- XS Dopa, NOR & Glutamate
- Altered levels of histamine serotonin & GABA

19
Q

In terms of neurotransmitters what type of state is delirium thought to be?

A

Hypocholinergic - hyperdopaminergic state

20
Q

What role does ACh have in delirium?

A

ACh thought to be reduced
- linked to EEG slowing
- reduced ACh thought to increase delirium - however low levels of ACh are not found in all cases of delirium

21
Q

What role do histamine receptors have in delirium?

A

H1 and H2 antagonists can cause sedation and delirium

22
Q

How does dopamine affect delirium?

A

Thought to be increased levels of dopamine in delirium - however there is an inconsistent response in Ps to antipsychotics.

23
Q

What is the role of NOR in delirium?

A
24
Q

Which drugs are associated with delirium?

A
25
Q

What is the neural network disconnectivity theory of delirium?

A

Brain is connected in functional networks - when stressed these can fail to connect = failure of normal brain function. Thought this might be a final driver in delirium.

26
Q

Which is the preferred tool recommended by NICE for diagnosing delirium?

A

4AT

27
Q

What is SQiD?

A

Single question in delirium - Is this P more confused than before? Very crude measure.

28
Q

What does new confusion score in NEWS2?

A

3 points

29
Q

Apart from 4AT and SqID - what is another useful tool for identifying delirium in Ps?

A

Short CAM

30
Q

How do we manage delirium?

A

Full comprehensive medical assessment - identify all possible causes of delirium
Systematically address any causes
Correct sensory impairment
Re-orientation
Optimise hydration, bowels and bladder function
Undertake comprehensive medication review

31
Q

How do we prevent delirium?

A
32
Q

What leaflet can be given to Ps to support them with their care in cases of delirium or dementia?

A

The This is Me Leaflet

33
Q

What method should you employ to deal with distressed delirious patients?

A

Apparently not any form of sedation for the patient - although you yourself might want to pop a diazepam.

Use verbal and non-verbal techniques to de-escalate the situation.

34
Q

When can you give drug treatments in delirium for distressed patients?

What should you give?

A

Can give Dx if P is
- Distressed
- A risk to themselves or other
- Verbal and non-verbal de-escalation techniques have failed

Start with Haloperidol - lowest dose for shortest time
DO NOT give in Parkinson’s or LBD - use benzos instead.

Antipsychotics may be used if severe hallucinations / delusions
Melatonin may be given for sleep disorders

35
Q

What is the median recovery period for a P with delirium?

What does duration depend on?

What percentage of Ps will have Sx at 3 months?

A

Median duration = 1 week

Duration depends on severity of the precipitant

1/3 of Ps have Sx at 3m

36
Q

How long would delirium Sx have to persist in order to diagnose a chronic cognitive impairment?

A

6 m +

37
Q

What is a significant drop in BP defined as?

A

A reduction of 20/10 mmHg within 3 mins of standing

38
Q

What are the four features of the CAM (Confusion Assessment Method) Alogorithim?

A

(1). Acute onset and fluctuating course - is there an acute change in mental status? Does the behaviour fluctuate?

(2). Inattention - doe the patient have trouble keeping track of what is said? Easily distractible?

(3). Disorganised thinking - is their thinking disorganised, rambling, irrelevant or illogical?

(4). Altered levels of consciousness - alert, vigilant (hyper alert), lethargic (drowsy by easily roused), stuporose (difficult to arouse) or comatose (unrousable)?

Diagnosis of delirium requires presence of 1 & 2 and either 3 or 4.