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1.Aged Care > COGNITION: Delirium/Dementia/Depression > Flashcards

COGNITION: Delirium/Dementia/Depression Flashcards

1
Q

COGNITIVE DOMAINS

A

1) Learning & Memory
2) Language
3) Praxis - ability to plan & then execute movement
4) Visuospatial fx - manipulate object in 3D space (e.g.: lost in familiar places, difficulty dressing self)
5) Executive fx - ability to plan & perform abstract reasoning
6) Attention/Concentration

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2
Q

What ADVERSE OUTCOMES are associated with DELIRIUM

A
  • ↑ length of hospital stay
  • Functional decline
  • Pressure sores
  • Incontinence
  • ↑ falls & significant injuries e.g.: fractures
  • ↑ discharge to residential care
  • ↑ overall mortality
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3
Q

Pathogenesis of DELIRIUM

A

[POORLY UNDERSTOOD]

Delirium occurs when a person’s mental capacity is overwhelmed.

If the person, when well, has an impaired mental ability, eg dementia, even a mild illness can cause a delirium.

A delirium occurs when the cognitive frailty and metabolic challenge exceeds a person’s reserve resulting in cognitive failure.

14-24% of older patients have a delirium on admission to hospital and up to 56% develop delirium during a hospital stay.

[UNDERRECOGNISDE]Only a third to a half of these cases are recognised and appropriately managed.

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4
Q

WHO GETS DELIRIUM?

Predisposing & Precipitating factors for DELIRIUM

A

inverse relp btw host vulnerability & severity of precipitating factors ie: vulnerable patients often develop delirium as a result of seemly trivial insults

PREDISPOSING FACTORS
• advanced age
• impaired cognition
• Prev Hx of DELIRIUM
• Depression
• Functional disability
• Visual & hearing impairment
• Dehydration
• Malnutrition
• Drugs
• Presence of chronic disease
PRECIPITATING FACTORS
• Drugs
• primary neurological diseases
• intercurrent illness
• malignancy
• surgery
• unfavourable environmental factors (e.g.: IDCs, other hospital interventions)
• prolonged sleep deprivation

NB: Risk is MULTIPLICATIVE!
- delirium is rarely caused by a single factor

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5
Q

DEFINE: DELIRIUM

A

[MEDICAL EMERGENCY] - clinical dx

acute confusional state, characterised by fluctuating symptoms of:
• inattention
• disorganised thinking
• impaired cognition
• altered conscious state

(altered sleep-wake cycle, perceptual disturbances & emotional disturbances)

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6
Q

What are the types of delirium?

A

HYPERactive (25%) = agitation & vigilance, repetitive behaviours, wandering, hallucinations or verbal/physical aggression

HYPOactive (25%) = pt appear quiet & withdrawn ( easily missed & misDx as depression)

MIXED pattern (35%) = fluctuations & lucid intervals

Normal Psychomotor activity (15%)

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7
Q

Cognitive Ax tool for DELIRIUM

A

Confusional Assessment Method (CAM)

  1. acute onset & fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Altered level of consciousness

Dx = 1 AND 2 + 3 OR 4

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8
Q

Aside from Ax cognition, how else can you assess for delirium on Hx?

A

Delirium can cause SOMATIC COMPLAINTS such as:
• Gait & Balance disturbances
• Falls
• general deterioration in function (functional decline)
• urinary incontinence
• faecal incontinence

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9
Q

[Yale Delirium Prevention Trial] - what are the 6 risk factors that if managed reduced rates of delirium significantly?

A

[Yale Delirium Prevention Trial]

Management of 6 risk factors
• cognitive impairment
• sleep deprivation
• immobility
• visual impairment
• hearing impairment
• dehydration
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10
Q

How do you prevent delirium in pts with HIP fractures?

A
  • involvement of geriatrician/physician
  • early surgery
  • appropriate analgesia
  • O2 delivery & fluid Mx
  • medication review
  • early mobilisation
  • reg Ax of bowel & bladder fx
  • nutrition
  • prevention & Tx of post-op complications
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11
Q

Mx of DELIRIUM

A

PRINCIPLES

  • identify & treat underlying cause/s (Tx predisposing & precipitating factors) PROMPTLY
  • provide supportive care & prevent complications (e.g.: falls,
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12
Q

CLINICAL FEATURES of DELIRIUM

A

CLINICAL FEATURES
• Recent onset (hours – days) of confusion
• Severity fluctuates throughout the course of the day
• Impaired attention and concentration - eg difficulty subtracting serial 7’s, counting back from 30, or saying months of the year backwards
• Disorientation – not knowing correct time, day or place

OTHER FEATURES

  • Altered consciousness - drowsy or hyperalert eg easily distracted by sound or light (NB may fluctuate between these states over the course of hours)
  • Altered sleep-wake cycle (awake at night / sleepy during day)
  • Often agitated e.g.: constantly picking at bedclothes or the air, rambling speech
  • Commonly have:
    • visual hallucinations
    • delusions
    • paranoid ideation regarding care- eg seeing insects crawling over their sheets believe they are being poisoned by medication, or believe the hospital staff are prison guards
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13
Q

Common causes of delirium in hospitalised patients

A

INFECTION: UTI, cellulitis, intra-abdo (appendix, diverticulitis, cholecystitis)

Medications:

  • opioids, anti-ACh, sedatives, steroids, anti-psychotics, anti-parkisons
  • Med TOXICITY eg: digoxin, lithium, phenytoin
  • WITHDRAWAL - EtOH, benzos

EtOH intoxication orwithdrawal

Post-surgery

Neurological: CVA, head injury, subdural haematoma

Metabolic: HYPER or HYPO: Na+, glucose, thyroid. renal or liver failure

Cardiac: CCF or AMI

PAIN

CONSTIPATION

URINARY RETENTION

Benzo withdrawal

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14
Q

h

A

h

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15
Q

h

A

h

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17
Q

PREVENTION of delirium?

A

ENVIRONEMENTAL strategies:

  • familiar staffing if possible
  • avoid room changes
  • even lighting appropriate to time of day
  • quiet environment, esp at night
  • provide orientation aids e.g.: clocks, calendars
  • encourage regular family presence (esp late arvo, early evening when confusion is often worse - coincide with evening meal to encourage intake)

FURTHER strategies
• clear communication to pt & family
• ORIENT patient @ every interaction (introduce self, plan of action, time & place)
• encourage oral intake
• ensure sensory aids are available & functioning (e.g.: vision & hearing )
• avoid consitpation & urinary retention
• encourage mobilisation
• review medications
• manage pain
• facilitated sufficient sleep
• minimise use of indwelling catheters

NB: AVOID USE OF PHYSICAL RESTRAINTS

18
Q

CAUSES of Delirium (acronym)

A

D: Dehydration / Deficiencies (eg: B12, thiamine) / Discomfort (pain!)

E: Electrolytes (Na/Ca/PO4) / Environment (unfamiliar)

L: Lungs (hypoxia) / Liver / Lack of Sleep / Long ED stay

I: Infection / intoxication / iatrogenic

R: Restricted mobility / renal failure

I: Injury / Infarction / Impaired sensation (hearing & vision)

U: UTI

M: Metabolic abnormalities / Metastases / Medications

19
Q

Differential for delirium?

A

1) DEMENTIA = main Ddx, distinguishing features are:
- onset: usually insidious (months - years) vs acute hours or days with delirium
- dementia does not fluctuate over minutes/hrs like delirium does
- dementia not assoc with changes in conscious state (until v late stages)
- attention usually preserved until late

NB: delirium can occur on a background of dementia/cognitive impairment
- any acute onset of behavioural disturbance should be presumed to be delirium

2) DEPRESSION
- normal consciousness
- attention may be poor
- memory usually intact when able to concentrate
- may have delusions related to mood

3) PSYCHOTIC DISORDER
- unimpaired consciousness
- orientation & memory usually intact
- may have complex delusions +/or hallucinations

4) ACUTE STRESS DISORDER
- precipitated by exposure to a severely traumatic event

NB: beware the quiet withdrawn patient who appears depression - they may have a hypoactive delirium

20
Q

What INVESTIGATIONS should you order in a DELIRIUM SCREEN?

A

1st line:

1) Bloods
- FBE
- CRP/ESR
- UEC
- CMP
- LFTs
- TFTs
- ? Blood cultures
- glucose levels

2) Urine MSU
3) CXR
4) Pulse oximetry

If clinically indicated

  • ECG / trops / CK
  • CT Brain
  • Drug levels e.g.: digoxin/ lithium/ anti-convulsants

2nd line:

  • B12, folate (if not recently performed/dementia suspected)
  • INR: if bleeding or liver failure suspected
  • arterial blood gases (if low O2 sats)
  • HIV
  • syphillis serology
  • LP if suspect encephalitis/meninigitis

1.Aged Care (5 decks)

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