Acute Confusion (Delirium) Flashcards
What is delirium?
Acute brain failure:
A syndrome of:
- Acute onset, typically over hours or days.
- Followed by a fluctuating course.
- With impaired attention and altered awareness.
- e.g. hallucinations.
- And a variety of cognitive and neuropsychiatric disturbances.
-
Cannot be explained by another pre-existing condition.
- e.g. dementia.
Thought that up to 30% delirium may be preventable.
What is the DSMs five diagnositc criteria for delirium?
Short answers:
- A disturbance of attension/awareness.
- Develops acutely (hrs/days).
- There is an additional disturbance in congition (memory, perception).
- It cannot be explained by a pre-existing condition (e.g. dementia).
- Evidence that is by direct consequence of another medical condition (e.g. drug abuse, medication).
Full criteria:
- A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
- The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
- An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
- The disturbances are not explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
- There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.
If you already have dementia, how does deliruim affect the progression?
It increases the rate of progression of your dementia.
(doubles the rate of cognitive decline in first year after hospital admission with delirium)
Also, having dementia increases your risk of developing delirium 5x!!!
The mnemonic, DELIRIUM, is used to remember the causes of it. What does each letter stand for?
Drugs;
- (withdrawal/toxicity, anticholinergics)/Dehydration.
Electrolyte imbalance.
Level of pain.
Infection/Inflammation;
- (post-surgery).
Respiratory failure;
- (hypoxia, hypercapnia).
Impaction of faeces.
Urinary retention.
Metabolic disorder (liver/renal failure, hypoglycaemia) / Myocardial infarction.
What subtypes of delirium exist?
Three subtypes:
-
Hyperactive,
- Restless, agitated, aggressive.
-
Hypoactive,
- Withdrawn, quiet, sleepy.
- Hard to notice.
- Mixed.
What conditions need to be met to diagnose delirium?
Need to have both 1 and 2, PLUS 3 or 4.
- Acute onset and fluctuating course.
-
Inattention,
* (distractable, cannot communicate). -
Disorganised thinking,
* (illogical, rambling). -
Altered consciousness,
* (hypo/hyper-alert).
When diagnosing delirium, how would you meet condition 1;
Actue onset and fluctuating course?
Identifying a change from baseline.
Collateral history (family and staff);
- Do you think (name of patient) has been more confused lately?
- Single Question in Delirium (SQiD),
- “Has ‘person’ been more confused lately?”
- 80% sensitive and 70% specific,
When diagnosing delirium, how would you meet condition 2;
Inattention?
Difficulty maintaining attention or shifting attention between tasks.
May be manifested by:
- Vagueness,
- Distracted by sounds, objects, thoughts.
Bedside tests of attention:
- Counting 20 to 1 backwards,
When diagnosing delirium, how would you meet condition 3;
Disorganised thinking?
Problems making sense of what is going on.
Misinterpreting the environment.
- May be hallucinations or persecutory ideas.
Mumbling or rambling speech which is difficult to understand.
When diagnosing delirium, how would you meet condition 4;
Altered conscious level?
Are they hyper/hypo-alert?
-
Hyper-alert:
- Agitated,
- Restless,
- Aggressive,
- Disturbed sleep.
-
Hypo-alert (easily missed):
- Sleepy,
- Withdrawn,
- No interest in environment.
- Poor oral intake.
What are some high-risk medications for delirium?
Analgesics:
- NSAIDs, opioids.
Anticholinergics:
- Atropine, benztropine, diphenhydramine, scopolamine
Antidepressants:
- Mirtazapine, SSRIs, TCAs
Sedative-hypnotics:
- Benzodiazepines, propofol.
Corticosteroids:
- Hydrocortisone, prednisone, methylprednisone, dexamethasone
Dopamine agonists:
- Amantadine, bromocriptine, levodopa, pergolide, pramipexole, ropinirole
Differentials for delirium?
Underlying dementia.
A stroke or a cerebrovascular incident.
Depression.
Hypoglycemia,
Hyperglycemia.
Hypoxia.
What are some management strategies for delirium?
Address acute medical issues;
- Drowsiness, constipation, infection, etc.
- Maintain hydration and nutrition.
-
Review medication;
- reduce or remove psychoactive drugs.
-
Treat withdrawal symptoms.
- alcohol/drug.
Re-orientate;
- Involve family.
- also, explain delirium to the family.
- Correct sensory impairment.
- Avoid moving around ward or between wards.
How could you optimise the environment for a delirious patient?
Avoid moving the patient between or around a ward;
- (especially at night).
Calm and quiet.
Natural light.
Clocks/calendars.
- So they can keep track of the day.
Eliminate unnecessary noises/bleeps/alarms especially at night.
Maintain safe uncluttered environment to reduce falls risk.
What are some drugs to treat delirium pharmacologically?
Haloperidol; (antipsychotic, Dopamine antagonist)
- Do ECG first,
- (Can prolong QTc interval).
Lorazepam; (short-acting benzodiazepine)
- (if antipsychotics contraindicated, e.g. Parkinson’s disease/parkinsonism, Lewy Body dementia, seizures, elongated QTc (>470ms)).
Chlordiazepoxide usually used for alcohol withdrawal.
