Acute confusion Flashcards
Define delirium
Acute, fluctuating and reversible state of confusion involving an impairment of conscious level (demonstrated by reduced GCS) and often involves psychotic symptoms
What factors suggest delirium over dementia?
Sudden change in behaviour
Top 3 suggest delerium
- Altered level of consciousness (reduced awareness of surroundings, sleep-wake cycle disturbances e.g. daytime drowsiness)
- Altered perception (e.g. illusions and hallucinations in 30%)
- Fluctuation of symptoms: worse at night, periods of normality
Others:
- Altered physical function- Hyper or Hypo (more common) delirium
- Altered social behaviour- changes in mood and/or emotions (such as fear, paranoia, anxiety, depression, irritability, apathy, anger, or euphoria)
- Inattention- easily distracted
- Disorganised thinking- rambling, irrelevant conversations
- Falling and loss of appetite are often warning signs for delirium.
What are causes of delirium?
PINCHME?
P- Pain- can worsen delierium? Urinary retention?
IN- Infection like UTI
C-constipation
H- Hydration/Nutrition- eletrolyte imbalances?
M- Medication
E- Environment
Symptoms of hyperactive delirium?
- Agitation
- Delusions
- Hallucinations
- Wandering
- Aggression
Symptoms of hypoactive delirium? (Most common type)
- Lethargy
- Slowness with everyday tasks
- Excessive sleeping
- Inattention
How would you assess a confused patient?
- History- ask about onset, nature and course of behaviour change, new illnesses, recent discharges, falls, pain, oral intake, changes in the environment, medications, alcohol, sensory impairment (vision and hearing)
- Cognitive assessment- Use GPCOG to assess baseline
- Clinical exam:
- Vital signs (e.g. fever in infection, low SpOin pneumonia, Bms)
- Level of consciousness (e.g. GCS/AVPU)
- Evidence of head trauma
- Sources of infection (e.g. suprapubic tenderness in urinary tract infection)
- Asterixis (e.g. uraemia/encephalopathy)
How is a diagnosis of delirium confirmed?
Cognitive assessment based on the
- Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria- disturbance to attention, cognition
- The short Confusion Assessment Method (short-CAM)- Need Confusion that has developed suddenly and fluctuates + Inattention, disorganised thinking and altered level of consciousness
- The 4A’s test- alertness, cognition, attention, acute/fluctuating changes
Management of delirium in primary care?
- Correct risk factors - infection, drug, constipation, urinary retention, dehydration + electrolyte imbalance, pain, sensory impairement
- Optimise comorbidity treatment e.g. COPD, DMs, Dementia, HF, TD, Parkinsons, Cerebovasc
- Advise family/careers- use reorientation strategies
List the supportive management/reorientation strategies used in delirium:
Reorientation strategies:
- Regular (at least three times a day) cues (for example explaining to the person who and where they are).
- Easily visible and accurate clocks and calendars.
- Continuity of care from carers and nursing staff.
- Encouraging visits from family or friends and exposure to familiar objects.
Maintain safe mobility:
- Avoid physical restraints such as cot sides.
- Encourage walking at least three times a day (provide walking aids if needed) or, if the person is unable to mobilize, try active range of motion exercises.
Normalize the sleep-wake cycle by:
- Discouraging napping and encouraging bright light exposure in the daytime.
- Encouraging uninterrupted sleep at night with a quiet room and low-level lighting.
What to do if they develop challenging behavior?
Address any underlying causes for the behaviour (such as discomfort, thirst, or need for the toilet).
Advise moving the person to a safe, low-stimulation environment (such as a quiet room).
Advise use of verbal and non-verbal de-escalation techniques (such as active listening, effective verbal responding, pictures, and symbols).
What is included in a confusion screen?
- Blood tests:
- FBC (e.g. infection, anaemia, malignancy)
- U&Es(e.g. hyponatraemia, hypernatraemia)
- LFTs(e.g. liver failure with secondary encephalopathy)
- Coagulation/INR(e.g. intracranial bleeding)
- TFTs(e.g. hypothyroidism)
- Calcium(e.g. hypercalcaemia)
- B12 + folate
- Glucose (e.g. hypoglycaemia/hyperglycaemia)
- Blood cultures (e.g. sepsis) - Urinalysis for UTI- A positive urine dipstick without clinical signs isNOTsatisfactoryto diagnose urinary tract infection
- Imaging
- CT head
- Chest x ray
What are the medication options?
Both off label
First line: Haloperidol (1 week or less)
- The risks (for example with haloperidol, an increased risk of stroke, transient ischaemic attack, and changes in cognition) and benefits (a small reduction in psychosis, aggression, and agitation)
Second line: Lorazepam
- if haloperidol is contraindicated (for example in people with Parkinson’s disease/parkinsonism, Lewy-body dementia, or a prolonged QT interval)
Haloperidol- MOA and dose
- Type: 1st gen antipsychotic
- MOA: D2 antagonism
- Dose: 0.25-0.5mg increase every 2 hours (Lower than that in BNF as per NICE). Max 2mg in 24 houts
Lorazepam- MOA, Dose, SI
Type: Rapid onset, short t1/2, intermediate-acting benzo
MOA: Indirect GabaA agonism, increasing GABA= Decreased neuronal excitability
Dose: 0.5mg-1mg increased after 2 hrs
SI: Daytime drowsiness, Dizziness, Muscle weakness, Ataxia.
CI: Respiratory depression, marked neuromuscular respiratory weakness (including myasthenia gravis), acute pulmonary insufficiency, or sleep apnoea syndrome, evere hepatic impairment (may precipitate encephalopathy).
How do you differentiate delirium from Wernicke’s encephalopathy?
Wernicke’s encephalopathy=
- Ataxia (unsteady gait)
- Ophthalmoplegia (Weakness of eye muscles)
- Nystagmus
- Confusion
