Ageing: Confusion Flashcards
What are 4 risk factors for delirium?
- Age > 65
- Cognitive impairment and/or dementia
- Current hip fracture
- Severe illness
If an individual with delirium becomes distressed, and verbal/non-verbal de-escalation techniques are ineffective, what medication would you administer?
0.5mg PO or 1mg IM Haloperidol (max 2mg/24h)
(given short-term; ≤ 1wk)
or Olazapine
In which 2 conditions is it inappropriate to give someone haloperidol for delirium?
- PD
2. Lewy Body Dementia
What are the 5 principles of the Mental Capacity Act?
- Capacity is assumed
- People should be helped to be able to decide
- People are allowed to be unwise
- Treat people in their best interest
- Use the least restrictive option
What screening tool can be used bedside to determine someone’s cognition?
AMTS 10 (or a shorter version called AMT 4)
What questions are asked in the AMT 4 mental test?
- Patient name
- Patient DOB
- Where they are
- Today’s date
List 10 things that can lead to delirium in an elderly patient?
- Recent surgery
- Poor sleep
- Pain
- Previous delirium
- Constipation
- Environment
- Dehydration
- Infection
- Hip Fracture
- Drugs
What is delirium?
Acute onset confusion with a change in alertness (i.e. agitated, hyper-alert)
What are the 2 validated tools that can be used to diagnose delirium?
- 4AT
- CAM (confusion assessment method)
- Should be performed at every consultation with this patient to monitor changes
What does it mean to be Confusion Assessment Method (CAM) positive?
A patient must have 1 + 2 + 3 or 4:
- Acute onset + fluctuating course
- Inattention
- Disorganized thinking
- Altered level of consciousness
What are the 4 components to the 4 AT assessment method?
- Alertness
- AMT 4 (age, DOB, current location, current date)
- Attention (name months backwards from Dec)
- Acute/fluctuating course
4+ = possible delirium +/- cognitive impairment 1-3 = possible cognitive impairment 0 = delirium or cognitive impairment unlikely
What are 6 general measures that should be taken for all patients with delirium?
- Reassurance + re-orientation in calm environment, promoting normal sleep pattern
- Increase nursing observation
- Encourage mobility
- Increase oral intake
- Regular monitoring of AMTS
- F/u in community as episodes of delirium increase risk of future dementia
What medication should be given for delirium in patients with PD or LB Dementia?
0.5-1mg PO Lorazepam (max 2mg/24h)
What medication should be given for patients with delirium due to acute alcohol withdrawal?
Chlordiazepoxide (benzodiazepine)
What are 4 features of hyperactive delirium?
- Restless
- Agitated
- Heightened arousal
- Aggressive
What does hypoactive delirium look like?
- Drowsiness
- Increased sleeping
- Quiet/withdrawn behaviour
- Carphologia/floccillations (lint-picking hand movements)
Associated with higher mortality than hyperactive delirium!
What are the 2 main hypotheses for the pathophysiology of delirium?
- Direct brain insult (i.e. stroke, drugs, hypoxia)
2. Aberrant stress response (i.e. peripheral infection/injury)
What are 5 negative outcomes that are associated with delirium?
- Longer hospital stays
- Increased incidence of dementia
- Increased complications (falls, pressure ulcers)
- Increased rate of admission to longterm care
- Increased mortality
Why is there a very high false positive rate for UTI urine dipstick in the elderly (>65y)?
Due to the presence of asymptomatic bacteriuria
What results are positive on a urine dipstick for UTI?
- Leukocytes
2. Nitrites
What are the 4 main signs/symptoms of pyelonephritis?
- Kidney pain/tenderness in back, under ribs
- New/different myalgia; flu-like illness
- Nausea/vomiting
- Shaking chills (rigors)/abnormal temperature
What are the 7 UTI symptoms/signs in patients over 65?
- New onset dysuria alone
OR 2+:
1. Abnormal temperature (> 1.5C their normal) 2x in the last 12h
- New frequency/urgency
- New incontinence
- New/worsening delirium/debility
- New suprapubic pain
- Visible hematuria
What are the most common causes of delirium?
PINCH ME
P-pain I-infection N-nutrition (poor) C-constipation H-hydration (poor)
M-medication
E-environment change
You are asked during the night shift to see a 90 year old man on the respiratory ward. He has become agitated and is trying to hit staff. They have managed to calm him down and do observations which are normal except for a HR of 100. You review him and notice that he appears to have lower abdominal pain and has some lower abdominal fullness on examination. He appears agitated. Apart from this, his examination is otherwise completely normal. You review his medications, he has not been started on any new medications this admission.
What are the MOST LIKELY causes of his sudden change in his behaviour and likely delirium?
Constipation and/or urinary retention
