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Year 4 - ACH > ACH - Confusion / Delirium > Flashcards

ACH - Confusion / Delirium Flashcards

1
Q

When a person 1st presents to hospital or long-term care, what 4 risk factors increase the likelihood of delirium?

A
  1. > 65 yrs old
  2. Cognitive impairment (past or present) and/or dementia
    • If cognitive impairment is suspected, confirm it using a standardised and validated cognitive impairment measure e.g. AMT-10 (abbreviated mental test)
  3. Current hip #
  4. Severe illness - i.e. a clinical condition that is deteriorating or is at risk of deterioration
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2
Q

What is hypoactive delirium?

A

Hypoactive delirium = subtype of delirium haracterised by people who become withdrawn, quiet and sleepy

Features:

  • Cognitive function: ↓ concentration, slow responses
  • Physical function: ↓ mobility, ↓ movement, changes in appetite
  • Social behaviour: withdrawal
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3
Q

What is delirium?

A

It is an acute state of confusion - associated with a syndrome of symptoms

Features:

  • Affects up to 30% of elderly hospital admissions
  • Memory disturbances (loss of short term > long term)
  • Agitation or withdrawn
  • Disorientation
  • Mood change
  • Visual hallucinations
  • Disturbed sleep cycle
  • Poor attention / concentration
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4
Q

If you suspect a patient of being at high risk of delirium what actions might you want to take?

A
  1. Inform family / carers that delirium is 1) common 2) temporary
  2. Describe examples of delirium to patient / family / carers
  3. Encourage patient / family / carers to tell the healthcare team if they notice sudden changes or fluctuations in behaviour
  4. Document any reported delirium concerns in pt notes
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5
Q

Various measures can be put in place to combat / reduce the risk of delirium in hospital admissions. For the following categories think of some measures to reduce the risk of delirium.

  • Cognitive impairment / disorientation
  • Dehydration and/or constipation
  • Hypoxia
  • Infection
  • Immobility / limited mobility
  • Pain
  • Sleep disturbance
A
  • Cognitive impairment / disorientation
    • Clear lighting and signage
    • Visable clock + calender
    • Talk to pt to reorientate them: explain where they are, who they are and who you are
    • Facilitate family/friend visitation
  • Dehydration and/or constipation
    • Encourage fluid intake
    • Consider S/C or IV fluids
  • Hypoxia
    • Optomise O2-sats as appropriate
  • Infection
    • Examine pt for infection
    • Avoid unnecessary catheterisation
  • Immobility / limited mobility
    • Encourage mobilisation soon post-op
    • Provide appropriate walking aids (accessible at all times)
  • Pain
    • Ask if patient is in pain
    • Look for non-verbal signs of pain / attempting to ‘grin and bear’ in pts with communication difficulties / learning difficulties
  • Sleep disturbance
    • ​Avoid nursing/medical procedures during sleeping hours
    • ↓ noise during sleeping hours
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6
Q

Delirium is often managed by treated the underling cause and ensuring patient is well orientated (with aid of family). But for pts with delirium who are distressed or risk to themselves or others, what steps can be taken?

A
  1. 1st line = De-escalate the situation –> talk to the patient (calmly), ensure their concerns are heard and acknowledged and where possible act to address them
  2. 2nd line = consider short-term ( < 1 week) haloperidol (0.5mg orally or 1mg IM, max 2g/24hrs) or olanzapine
    1. Use antipsychotics at the lowest clinically appropriate dose
    2. DON’T use antipsychotics in PD or dementia with Lewy bodies - consider lorazepam in these patients
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7
Q

What standardised tools can be used for assessing cognitive impairment?

A
  1. AMT - 10 (Abbreviated mental test - 10) - 10 point test which is far simpler than a MoCA (there is an even simpler version, the AMT-4)
  2. MoCA (Montreal Cognitive Assessment) - 30 point test, supposed to take 10 mins
    • Assesses: Visuo-spatial, executive, naming, memory, attention, language, recall etc.
    • https://www.parkinsons.va.gov/resources/MOCA-Test-English.pdf
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8
Q

Of the following medications, which ones could contribute to a patient’s confusion/delirium?

  • Dihydrocodeine
  • Simvastatin
  • Bendroflumethiazide
  • Ferrous sulphate
  • Paracetamol
A
  1. Dihydrocodeine - can cause confusion direcetly or indirectly via causing constipation
  2. Bendroflumethiazide - can cause hyponataemia or dehydration and thus contribute to confusion
  3. Ferrous sulphate - can cause constipation leading to delirium
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9
Q

Name 2 tools that can be used to assess / diganose delirium?

A
  1. CAM (Confusion assessment method)
  2. 4AT (4 A’s test)
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10
Q

What 4 features are part of the CAM assessment method for delirium?

A

Delirium = features 1 + 2 + either 3 or 4

  1. Acute onset and fluctuating course
    • PLUS
  2. Inattention (counting backwards or reduced attention during review)
    • PLUS
  3. Disorganised thinking (incoherent disorganised speech)
    • OR
  4. Altered level of conciousness (hyperalert, hypoalert, or both)
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11
Q

What are the 4 sections/categories of the 4AT test and what is involved in each?

What score is required for possible delirium?

A
  1. Alertness
    • Normal / Fully alert / Mild sleepiness on waking = 0
    • Clearly abnormal (drowsy / hypoactive or agitated / hyperalert) = 4
  2. AMT4 - ask the pt the following: their age, DoB, current year and current location
    • No mistakes = 0
    • 1 mistake = 1
    • 2 or more mistakes/untestable = 2
  3. Attention - ask the pt to name the months backwards starting at December
    • 7 or more correctly = 0
    • Less than 7 or does not attempt = 1
    • Untestable (drowsy/inattentive) = 2
  4. Acute and fluctuating course
    • No = 0
    • Yes = 4

Diagnosis:

  • 4 or above = possible delirium +/- cognitive impairment
  • 1 – 3 = possible cognitive impairment
  • 0 = delirium or cognitive impairment unlikely
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12
Q

A 75 year old gentleman has a urine disptick with the following results:

Leucocytes ++, nitrites +ve

What does this indicate?

A

Not a lot!!

  • Urine dipsticks are a very poor predictor of UTI in older people as they have a very high false positive rate i.e. bacteriuria is common
  • urine dipsticks should not be used in people over 65 to diagnose urinary tract infections
  • If YOUNG then would suggest a UTI
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13
Q

What is buprenorphine?

A

It is an opiod receptor partial agonist (opiod agonists + antagonist properties)

  • Can be given in patch form (Butrans patch) - for mild-moderate pain, unresponsive to non-opiod analgesics
  • Can also be given sublingually, IM and slow IV injection
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14
Q

Morphine isn’t always well tolerated in elderly patients what opiod alternative could be used?

A

Oxycodone

  • Administered: orally (immediate or modified release), subcut, slow IV injection, infusion
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15
Q

Withdrawal from medication can cause delirium, but withdrawal from what else can also cause delirium?

A

Alcohol

  • Alcohol withdrawal 1st line = benzodiazepines e.g. chlordiazepoxide
  • In hepatic failure –> consider lorazepam
  • Carbamazepine (anti-epileptic/convulsant) also effective in treatment of alcohol withdrawal
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16
Q

In patients with alcoholism, what are they at risk of being deficient of? what can this cause? what is given to prevent this occuring?

A
  1. At risk of thiamine (B1) deficiency
  2. Deficiency puts patient at risk of Wernicke’s encephalopathy
  3. Prevented with thiamine supplements
17
Q

What are the 2 types of delirium, based on behaviour?

What are their features?

A
  1. Hyperactive
    • Restlessness
    • Agitation
    • Heightened arousal
    • Aggression
  2. Hypoactive
    • Drowsiness
    • ↑ sleeping
    • Quiet or withdrawn behaviour

Note: Hypoactive delirium is often more difficult to identify, as are those with a ‘mixed’ picture

18
Q

What condition is difficult to differentiate from delirium and is a risk factor for delirium?

A

Dementia

  • If uncertain about dementia vs delirium –> treat as delirium until proven otherwise
19
Q

What proportion of patients who are diagnosed with delirium and have the causes treated go on to recover?

A

2/3rds!!

(1/3 quickly and 1/3 slowly)

  • 1/3rd of patients don’t completely recover –> often admitted to care home or die
20
Q

Delirium is associated with various -ve outcomes, try and name some (5 listed)

A
  1. Longer hospital stays
  2. Increased incidence of dementia
  3. Increased complications such as falls and pressure ulcers
  4. Increased rate of admission to long-term care
  5. More likely to die
21
Q

What symptoms should be used in the elderly population (as well as the young, but here urine dipstick is also useful) to diagnose UTI?

A

Consider starting Abx for UTI if any 2 of the following are present:

  1. Dysuria
  2. Frequency or urgency
  3. New urinary incontinence
  4. Delirium
  5. Suprapubic pain
  6. Haematuria

Flowchart for ?UTI > 65 yrs: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/755889/PHE_UTI_flowchart_-_over_65.pdf

22
Q

You have been asked to review an 80-year-old residential home resident, who has a history of vascular dementia. She has become drowsy and withdrawn over the last two days, with intermittent episodes of agitation. She is referred to hospital by her GP with a possible delirium. Which of the following statements is CORRECT?

  • A history from the carers about her normal mental state should be sought as soon as possible
  • Cognitive testing using the AMTS is not indicated because she has a pre-existing diagnosis
  • Delirium is uncommon in patients with pre-existing dementia
  • People with delirium are usually hyperalert and agitated
  • The confusion assessment method (CAM) cannot be used in patients with dementia
A

A history from the carers about her normal mental state should be sought as soon as possible

  • Establishing baseline will allow you to determine whether this a delirium or not, and also what functional status we should be aiming for
23
Q

A 92 year old woman is referred with new confusion and disorientation. She has a past medical history of falls, urinary incontinence, hypertension and ischaemic heart disease. Her AMTS score is 4/10. You speak to her daughter who tells you that she lives alone and is usually not confused at all. You diagnose delirium. Her observations are BP 140/78, HR 105, RR 20, sats 98% on RA, Temp 37. Which of the following tests do you NOT request as first line investigation into their delirium?

  • Blood cultures
  • CXR
  • CT brain
  • Mid stream urine specimen
  • Serum Calcium
A

CT brain

  • Blood cultures - ?sepsis
  • CXR - identify source of infection
  • Mid stream urine specimen - urine dipstick to screen for sepsis / infection
  • Serum calcium - ↑↑ calcium can cause delirium
24
Q

Which of the following is NOT true?

Delirium leads to:

  • Increased falls and pressure ulcers
  • Increased incidence of dementia
  • Increased occurrence of heart attacks
  • Increased rate of admission to long-term care
  • Longer hospital stays
A

Increased occurrence of heart attacks

Year 4 - ACH (6 decks)

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