13.4 (17.5) Delirium Flashcards
List 6 domains of function that can be impaired with delirium
Attention
Disorganized thinking
Level of alertness
Psychomotor Behaviour
Mood
Sleep wake cycle
Perception
Cognition
FS: ADL - BMS
What is the DSM 5 definition of delirium
A. Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
E. There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.
FS - 5 criteria
1. Acute + fluctuating
2. Changing attention
3. Another cognitive deficit
4. Not due to a neuro cognitive issue (eg dementia)
5. Evidence that etiology is due medical condition / substance
List four neurotransmitters that are hypothesized to be involved in the pathophysiology of delirium
serotonin* dopamine* Increased GABA* (benzo) decreased glutamate acetylcholine*
FS: think nausea meds
What is the gold standard diagnostic method for diagnosing delirium? What are the three core features of the syndrome?
clinical assessment utilizing DSM criteria:
- disturbance in attention
- acute onset
- fluctuating course
List two delirium screening tools. Which is most well studied for patients with cancer or advanced illness
Confusion assessment method (CAM)
Nursing delirium assessment tool
4AT
MMSE
Memorial delirium assessment scale (MDAS)*
Delirium rating scale (DRS) - Revised 98*
*best studied for advanced illness/cancer
what criteria must be fulfilled in the CAM to detect delirium
- acute onset and fluctuating course
- inattention
- disorganized thinking
- altered LOC
If #1 AND #2 and one of #3/#4 are present a diagnosis of delirium is suspected
FS: AADL
List 8 risk factors for delirium in the hospitalized patient
age greater than 65
physical frailty
immobility
visual or hearing impairment
malnutrition
low albumin
comorbid illness
renal impairment
mets - brain, liver, bone
pre-existing cognitive impairment
dementia
admission to hospital with dehydration or infection
multiple medications (polypharmacy)
psychoactive medication
WP: tried to organize risk factors into groups
DIMS +
Demographic (age > 65, vision/hearing
Impairment, immobility, frailty)
What are two major subtypes of delirium? List one unique complication for both
Hyperactive - more falls
Hypoactive - more pressure sores and hospital acquired infection
List two features to differentiate delirium from depression
- degree of cognitive impairment much more severe in delirium
- more abrupt onset in delirium
- disturbance in level of alertness not seen in depression
FS: basically the AADL in CAM
List 2 features to differentiate mania from delirium
- Past psych hx of mania/depression or family hx often seen in mania dx
- disturbance in level of alertness and cognition not seen in mania
- temporal onset and course of symptoms differ
- medical etiology of delirium
FS: AADL + etiology (past/fam history vs medical)
List two features to differentiate delirium from psychosis
In delirium and not psychosis:
- context of advanced medical etiology
- disturbance of alertness
- impaired attention span
- memory impairment and orientation
FS: AADL + etiology
List three features to differentiate delirium from dementia
dementia has:
more severe cognitive symptoms,
poorer response to treatment
lower rate of resolution
preserved arousal
temporal onset more subacute & chronically progressive
FS: AADL in delirium
Dementia - more severe cognitive symptoms
What are the three principles for management of delirium
- Correction of underlying cause & treatment of symptoms and signs of disorder
- Identify occurences of lucidity to assess decisional capacity, understand regulations that apply to ACP & surrogate decision-making
- Pt’s preferences, particularly re: mental awareness at EOL
Fs:
1. Treat delirium (source and symptoms)
2. Response to illness
3. Future planning (GOC, SDM, POC)
List SIX non pharm interventions for delirium
◆ reorient patient frequently*
◆ place an orientation board, clock, familiar objects in room*
◆ minimize sensory deficits
- visual aids, adaptive equipment, amplifying devices, especial communication devices*
◆ encourage cognitively stimulating activities
◆ sleep cycle preservation*
◆ reducing polypharmacy
◆ control of pain*
◆ monitor fluid/electrolyte disturbances
◆ optimize nutrition*
◆ optimize hydration*
◆ encourage early mobilization
- minimize use of immobilizing catheters, IV poles & phys restraints
◆ monitor bowel/bladder function*
FS:
- Orientation
- Aids (hearing, vision, ambulating)
- Activate
- Sleep
- Intake
- BM/urine
WP: OASIS = hydration/nutrition
Orient frequent/boards
Aids: visual/audio
Sleep cycle
Immobile dec: early mob, no restraints, d/c foley
Stim activities
What is the first-line pharmacological class used for the management of symptoms in delirium
Antipsychotics, in the setting where:
- non pharm strats have been ineffective
AND
- delirious pt is distressed or a risk to themselves/others
