6 - Delirium

Question 1

Delirium definition

Answer 1

Altered mental status with at least 2 of 6:

• disturbance of consciousness
• perceptual disturbance
• sleep-wake cycle disturbance
• increase/decrease in psychomotor activity
• disorientation to person/place or time
• memory impairment

Question 2

What is disturbance of consciousness?

Answer 2

Either:

• hyperviligant (w etoh/benzo withdrawl)
• somnolent (w infection or metabolic derangement)

Question 3

Characteristics of delirium?

Answer 3

• Acute onset, short course (hours - days)
• fluctuating course (cognitive function good in AM, bad in PM)
• is co-morbid condition (not primary condition - seek a cause)
• pts may recover fully if cause is treated

Question 4

What is often the initial point of entry for geriatric hospital admissions?

Answer 4

Delirium

Question 5

Delirium is commonly seen in?

Answer 5

ED
Inpatient services
Long term care facilities

• so anywhere old/homeless people go

Question 6

Medication causes of delirium?

Answer 6

Anticholinergics
Antipsychotics
Benzodiazepines
Corticosteroids
H2-receptor antagonist
Sedative hypnotics

Question 7

What is the cause of 40% of delirium cases?

Answer 7

Antipsychotics

Question 8

Delirium effects ___ % of surgical and ___% of elderly medical pts

Answer 8

10-15% of surgical patients
33 % of elderly medical inpatients

She said 1/3 of the elderly but who the fuck goes back and forth between percents and fractions in a single sentence? Honestly WTF

Question 9

Delirium and infections?

Answer 9

Can be a manifestation of infections

• delirium may be the only manifestation of pneumonia in a geriatric pt

Question 10

Risk factors for nursing home residents/community acquired pneumonia?

Answer 10

Alcoholism
Asthma
Immunosuppression
Age (>70)
Difficult swallowing
Inability to take oral meds
Profound disability
Bedridden state
Urinary incontinence

Question 11

MCC of pneumonia in the elderly?

Answer 11

Streptococcus pneumoniae

Question 12

Risk factors and precipitating factors for delirium?

Answer 12

Age
Seizure d/o
Metabolic d/o
Drug/etoh abuse/withdrawal
Psychoactive pharmacologic drugs
Structural brain damage
- stroke, Alzheimer’s, trauma

Question 13

Diagnosis of delirium (levels)

Answer 13

Mild delirium
Severe delirium
Illusions, hallucinations, delusions

Question 14

Mild delirium presentation?

Answer 14

Disturbed sleep
Mild tachycardia
Sundowners syndrome

Question 15

Severe delirium

Answer 15

Pt is disoriented, unable to follow simple requests

Question 16

Physical signs that can present with delirium?

Answer 16

Tachycardia
Diaphoresis
Autonomic instability 
- (HTN, HOTN)
Tremor
Myoclonus
Purposeless movements

Question 17

When assessing a delirious pt you should use?

Answer 17

CAM algorithm

Confusion assessment method

Question 18

features of CAM?

Answer 18

Must have 3/4 of:

• acute onset and fluctuating course
• inattention
• disorganized thinking
• ALOC (orientation)

Question 19

Before giving a rating for CAM you should?

Answer 19

Review med chart
Ask family/nurse
Brief cognitive assessment of pt

Question 20

CAM - acute onset and fluctuating course

- assessed via?

Answer 20

Evidence from a family member/nurse
Positive response to:
- is there evidence of an acute change in mental status from baseline?
- did the (abnormal) behavior fluctuate during the day?

Question 21

CAM - inattention

- assessed via?

Answer 21

Observation of presence of difficulty focusing attention

• easily distracted
• can track conversation

Question 22

CAM - disorganized thinking

- assessed via?

Answer 22

Observation of the presence of disorganized thinking or incoherent speech

• rambling
• irrelevant conversation
• unclear/illogical flow of ideas
• unpredictable switching from subject to subject

Question 23

CAM - altered LOC

- assessed via?

Answer 23

Based on the observation of the presence of a level of consciousness other than “alert” can be:

vigilant (hyperalert)
hyopoalert 
- lethargy
- stupor
- coma

Question 24

Diagnostic eval is geared toward?

Answer 24

Finding the cause

- delirium often reflects abnormal CNS function 2/2 systemic infections and metabolic d/o

Question 25

Labs you should order for delirium?

Answer 25

Electrolytes
BUN
CMP
Cultures

EKG
CXR

Question 26

Treatment for delirium?

Answer 26

DC/reduce psychoactive meds

Thiamine supplementation

Treat underlying cause

Manage delirious state via supportive care

• adequate nutrition
• fluid/electrolyte balance

Question 27

Management of delirious state?

Answer 27

• Provide well-lighted predictable environment
• utilize nursing staff/family to provide freq reorientation
• med staff should provide simple explanations for necessary procedures or confusing stimuli
• encourage pt to stay awake during the day and sleep at night
• agitated, hallucinating, delusional pts may require meds

Question 28

Anti-psychotics?

Answer 28

Typical anti-psychotics
- haloperidol (haldol)

Atypical anti-psychotics

• quetiapine (seroquel)
• risperidone (risperdal)

Benzodiazepines

Question 29

Elderly dose for haloperidol?

Answer 29

Low dose 0.5-1.0 mg PO/IM

Question 30

What med (class) commonly used with anti-psychotics dont have much of a role in the elderly?

Answer 30

Benzodiazepines

• limited role only
• not 1st line

Question 31

Delirious pts are at a higher risk for?

Answer 31

Falls

• req constant observation by fam/nurses
• physical restraints (last resort)

Question 32

The shovel

Answer 32

Was a ground breaking invention