6 - Delirium Flashcards
Delirium definition
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
What is disturbance of consciousness?
Either:
- hyperviligant (w etoh/benzo withdrawl)
- somnolent (w infection or metabolic derangement)
Characteristics of delirium?
- 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
What is often the initial point of entry for geriatric hospital admissions?
Delirium
Delirium is commonly seen in?
ED
Inpatient services
Long term care facilities
- so anywhere old/homeless people go
Medication causes of delirium?
Anticholinergics Antipsychotics Benzodiazepines Corticosteroids H2-receptor antagonist Sedative hypnotics
What is the cause of 40% of delirium cases?
Antipsychotics
Delirium effects ___ % of surgical and ___% of elderly medical pts
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
Delirium and infections?
Can be a manifestation of infections
- delirium may be the only manifestation of pneumonia in a geriatric pt
Risk factors for nursing home residents/community acquired pneumonia?
Alcoholism Asthma Immunosuppression Age (>70) Difficult swallowing Inability to take oral meds Profound disability Bedridden state Urinary incontinence
MCC of pneumonia in the elderly?
Streptococcus pneumoniae
Risk factors and precipitating factors for delirium?
Age Seizure d/o Metabolic d/o Drug/etoh abuse/withdrawal Psychoactive pharmacologic drugs Structural brain damage - stroke, Alzheimer’s, trauma
Diagnosis of delirium (levels)
Mild delirium
Severe delirium
Illusions, hallucinations, delusions
Mild delirium presentation?
Disturbed sleep
Mild tachycardia
Sundowners syndrome
Severe delirium
Pt is disoriented, unable to follow simple requests
Physical signs that can present with delirium?
Tachycardia Diaphoresis Autonomic instability - (HTN, HOTN) Tremor Myoclonus Purposeless movements
When assessing a delirious pt you should use?
CAM algorithm
Confusion assessment method
features of CAM?
Must have 3/4 of:
- acute onset and fluctuating course
- inattention
- disorganized thinking
- ALOC (orientation)
Before giving a rating for CAM you should?
Review med chart
Ask family/nurse
Brief cognitive assessment of pt
CAM - acute onset and fluctuating course
- assessed via?
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?
CAM - inattention
- assessed via?
Observation of presence of difficulty focusing attention
- easily distracted
- can track conversation
CAM - disorganized thinking
- assessed via?
Observation of the presence of disorganized thinking or incoherent speech
- rambling
- irrelevant conversation
- unclear/illogical flow of ideas
- unpredictable switching from subject to subject
CAM - altered LOC
- assessed via?
Based on the observation of the presence of a level of consciousness other than “alert” can be:
vigilant (hyperalert) hyopoalert - lethargy - stupor - coma
Diagnostic eval is geared toward?
Finding the cause
- delirium often reflects abnormal CNS function 2/2 systemic infections and metabolic d/o
Labs you should order for delirium?
Electrolytes
BUN
CMP
Cultures
EKG
CXR
Treatment for delirium?
DC/reduce psychoactive meds
Thiamine supplementation
Treat underlying cause
Manage delirious state via supportive care
- adequate nutrition
- fluid/electrolyte balance
Management of delirious state?
- 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
Anti-psychotics?
Typical anti-psychotics
- haloperidol (haldol)
Atypical anti-psychotics
- quetiapine (seroquel)
- risperidone (risperdal)
Benzodiazepines
Elderly dose for haloperidol?
Low dose 0.5-1.0 mg PO/IM
What med (class) commonly used with anti-psychotics dont have much of a role in the elderly?
Benzodiazepines
- limited role only
- not 1st line
Delirious pts are at a higher risk for?
Falls
- req constant observation by fam/nurses
- physical restraints (last resort)
The shovel
Was a ground breaking invention
