15. Confusion/delirium Flashcards
definiton delirium - features??
Acute onset and fluctuating course
Inattention (inability to concentrate)
Disorganised thinking (rambling, illogical ideas)
Altered level of consciousness (hyper alert or drowsy)
presentation hyperactive delirium
restless, agitated, delusions, hallucinations, risk of harm to patient or others.
presentation hypoactive delirium
lethargic, drowsy, reduced communication
presentation mixed delirium
demonstrates signs of both hyper and hypo
Hyperactive delirium: restless, agitated, delusions, hallucinations, risk of harm to patient or others.
Hypoactive delirium: lethargic, drowsy, reduced communication.
Approach to acute confusion assessment
Speak to nurses about usual cognitive status, functional status, whats happened so far
History to gauge situation… ask about their hospital stay, where they are, why they are here
ask about confusion if possible? short term, long term? mood? visual hallucinations, sleep, attention
Pain
Infection - suprapubic pain, breathlessness, cough, sputum, headahce,
Nutrition - eating well, any electrolytes?
Constipation - opening bowels?
Hydration - drinking? goig for a wee? last wee?
Metabolic: hypercalcaemia
Environment
Cognitive test- AMT or 4AT
ABCDE approach to assessment
A
B - ?infection
C - fluid balance? fluid status? blocked catheter? ECG for arrythmias and metabolic cuases? get VBG!
D- GCS, hypogylcaemia? hyperglycaemia and ketones?
E- abdo pain? temp? think do i need sepsis 6
Review medications
Invetsigation acute confusional state
Confusion screen –>
Blood tests:
- FBC, U&E, LFT, Coagulation, TFTs, calcium, haematinics, glucose, cultures
Urinalysis
imaging
- CT head if indicated
- CXR if indicated
pre-disposing factors delirium
age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy
causes delirium
Pain
Infection
Nutrition
Constipation
Hydration
Metabolic: hypercalcaemia, hypo/hyperglycaemia, hyponautraemia
Environment
any significant cardiovascular, respiratory, neurological or endocrine condition
alcohol withdrawal
Management of delirium
- treatment of the underlying cause
+ modification of the environment - haloperidol 0.5 mg every 2-4 hours until there is a clinical response. or olanzapine.
USE FOR 1W OR LESS - lorazepam 0.5mg-1mg oral every 2 hours until response. max 2mg/24hr
USE FOR 48 hr OR LESS
what invetsigation is reccomended before halopeeridol initiation
An ECG is recommended before initiation of haloperidol, particularly if cardiovascular risk factors or a history of cardiovascular disease are present. ECG and blood pressure monitoring during treatment with haloperidol is advised.
Contraindictaions to haloperidol for delirium
- parkinsons, basal ganglia lesion or lewy-body dementia
- CNS depression or NM weakness
- cardiac disorder (CHECK) - qt prolonged, recent MI, HF, arryth, brady
