11 - Delirium Flashcards
What is delirium?
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.
What often happens to a P’s sleep-wake cycle in delirium?
It gets reversed
What cognition impairments are characteristic of delirium?
Hallucinations, disorientation and memory loss are characteristic of delirium
What are the subtypes of delirium?
Which is most common?
Hyperactive
Hypoactive
Mixed (most common)
Which subtype of delirium is associated with higher mortality?
Why?
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.
What other diseases present similarly to hypoactive delirium?
Severe depression
Post-ictal phase
Non-convulsive status epileptics
Encephalitis
What other diseases present similar to hyperactive delirium?
Dementia
Psychosis
How can you tell the difference between delirium and dementia?
Why is diagnosis of delirium important?
Extremely common & associated with adverse outcomes
What percentage of patients with delirium still have symptoms at six months?
20%
What is solifenacin used for?
Treatment for overactive bladder - is an anti-cholinergic medication.
How is the PINCHME mnemonic used in delirium?
Identifies possible causes of delirium
- Pain
- Infection
- Nutrition
- Constipation
- Hydration
- Medication
- Environment
When thinking about the cause of delirium - what is it important to remember?
That any medical illness can precipitate delirium - not just geriatric illnesses.
AND
Most cases of delirium are multifactorial
What are the predisposing factors to delirium?
Older age
Dementia or cognitive impairment
Frailty
What are the precipitating factors of delirium?
How long after stopping alcohol does delirium tremens start?
What symptoms are seen?
3-10 days
Commonly associated with tactile hallucinations, formication
Can cause seizures and is potentially life threatening
How is severity of stressor linked to delirium?
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.
What is the neurotransmitter hypothesis of delirium?
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
In terms of neurotransmitters what type of state is delirium thought to be?
Hypocholinergic - hyperdopaminergic state
What role does ACh have in delirium?
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
What role do histamine receptors have in delirium?
H1 and H2 antagonists can cause sedation and delirium
How does dopamine affect delirium?
Thought to be increased levels of dopamine in delirium - however there is an inconsistent response in Ps to antipsychotics.
What is the role of NOR in delirium?
Which drugs are associated with delirium?
What is the neural network disconnectivity theory of delirium?
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.
Which is the preferred tool recommended by NICE for diagnosing delirium?
4AT
What is SQiD?
Single question in delirium - Is this P more confused than before? Very crude measure.
What does new confusion score in NEWS2?
3 points
Apart from 4AT and SqID - what is another useful tool for identifying delirium in Ps?
Short CAM
How do we manage delirium?
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
How do we prevent delirium?
What leaflet can be given to Ps to support them with their care in cases of delirium or dementia?
The This is Me Leaflet
What method should you employ to deal with distressed delirious patients?
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.
When can you give drug treatments in delirium for distressed patients?
What should you give?
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
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?
Median duration = 1 week
Duration depends on severity of the precipitant
1/3 of Ps have Sx at 3m
How long would delirium Sx have to persist in order to diagnose a chronic cognitive impairment?
6 m +
What is a significant drop in BP defined as?
A reduction of 20/10 mmHg within 3 mins of standing
What are the four features of the CAM (Confusion Assessment Method) Alogorithim?
(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.
