Ageing - Delirium Assessment Flashcards
What are the 2 assessment tools for delirium?
Confusion assessment method (CAM)
4AT
What is the criteria for delirium using the CAM?
1) Acute change in mental status/ fluctuating mental status over the day
AND
2) Inattention - easily distracted or difficulty concentrating
AND
3) Disorganised thinking e.g. rambled speech
OR
4) Altered level of consciousness - hyper alert/ irritable or drowsy/ sleepy
How can you test for inattention in CAM?
Digit span test - <7 = abnormal
If a patient has delirium, what things should you check for that might be causing it? (10)
Check bloods: electrolytes and glucose Ensure good hydration Septic screen Check for and correct hypoxia ECG for MI/ arrhythmias Stop drugs with neurotoxic effects Relieve pain Avoid urinary catheter unless in retention Treat constipation Think about alcohol withdrawal
Nursing considerations for a patient with delirium? (7)
Familiar staff Avoid darkness Use glasses and hearing aids Avoid restraints Orientation (clock, calendar, photos) Low noise levels One to one nursing if agitated
If a patient with delirium remains distressed despite doing all the above, what medication can you give?
0.5mg haloperidol orally
What are the 4 sections of the 4AT?
Alertness
AMT4
Attention
Acute change or fluctuating course
In the 4AT, how many points do you get if the patient’s alertness is clearly abnormal?
4
What are the 4 parts of the AMT4?
Name
DOB
Place (name of hospital/ building)
Current year
How many points does the patient get if the make 1 mistake in the AMT4?
1
How many points does the patient makes 2 or more mistakes in the AMT4 or they are untestable?
2
How do you test attention in the 4AT?
Ask the patient to tell you the months of the year backwards (can give one prompt of “what is the month before December)
How many points does the patient get in the 4AT for attention if they start but score <7 months/ refuse to start?
1
How many points does the patient get in the 4AT for attention if they can’t be tested?
2
How many points does the patient get in the 4AT if there is evidence of significant change in alertness, cognition, other mental function arising over the last 2 weeks and still evident in the last 24 hours?
4
