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PHAR 350 > Cognitive Impairment (Delirium) > Flashcards

Cognitive Impairment (Delirium) Flashcards

1
Q

What is delirium according to the DSM-5? (4)

A
  1. Acute onset
  2. Disturbances in attention, awareness, and cognition
  3. Fluctuates in severity
  4. Attributable to an underlying cause
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2
Q

Delirium is an _____ ___________ state

A

acute confusional

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3
Q

What are 3 other features of delirium?

A
  1. Psychomotor disturbance
  2. Altered sleep-wake cycle
  3. Emotional lability
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4
Q

What is the significance of delirium? (4)

A
  1. Poor prognostic indicator
  2. Delirium is associated with:
    - 2x increased risk of death
    - 2.5x increased risk of discharge to higher level of care
    - 12.5x increased risk of developing dementia
  3. Increased length of hospitalization (5-10 days)
  4. Sustained functional decline 6 months after admission
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5
Q

What underlying vulnerabilities can cause delirium? (4)

A
  1. Cognitive dysfunction
  2. Frailty
  3. Age
  4. Stressor(s)
    - Hypoxia
    - Infection
    - Drugs
    - Pain
    - Hypoglycemia
    - Dehydration
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6
Q

What are some predisposing factors of delirium? (5)

A
  1. Increased age
  2. Dementia
  3. Functional impairment (baseline)
  4. Multimorbidity
  5. Others
    - Decreased vision and/or hearing
    - Mild cognitive impairment
    - Depression
    - Alcohol or drug use/withdrawal
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7
Q

What are some precipitating factors of delirium? (7)

A
  1. DRUGS
  2. Surgery/trauma
  3. Pain
  4. Anemia
  5. Infection
  6. Exacerbation of chronic illness
  7. Bedridden
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8
Q

What are the worst drugs in terms of causing delirium? (3 groups)

A
  1. Anticholinergics
    - TCAs
    - 1st gen antihistamines
    - 1st gen antipsychotics
    - Muscle relaxants
    - Antimuscarinics
    - Benztropine
  2. BZDs/Z-Drugs
  3. Opioids
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9
Q

What are the bad, but not worst drugs in terms of causing delirium? (4 groups)

A
  1. Anticonvulsants
    - Carbamazepine
    - Phenytoin
    - Topiramate
    - Gabapentin/pregabalin
  2. Dopamine agonists
  3. Amantadine
  4. Cannabis (THC/dose-related)
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10
Q

What drugs are less likely but can still possibly cause delirium? (4)

A
  1. Corticosteroids
  2. Psychoactive NSAIDs
  3. Digoxin
  4. Cannabis (CBD-based)
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11
Q

What is the most useful bedside tool used for diagnosing delirium?

A

Confusion Assessment Method (CAM)

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12
Q

The confusion assessment method (CAM) requires 1+2 with either 3 or 4. List 1 through 4 symptoms on the list

A
  1. Acute change in mental status with fluctuations
  2. Inattention
  3. Disorganized thinking
  4. Altered level of consciousness
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13
Q

What are the 3 delirium subtypes?

A
  1. Hyperactive delirium
  2. Mixed delirium
  3. Hypoactive delirium
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14
Q

What are the general symptoms of hyperactive delirium? (3)

A
  1. Combative
  2. Agitated
  3. Restless
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15
Q

What are the general symptoms of hypoactive delirium? (3)

A
  1. Drowsy
  2. Somnolent
  3. Unarousable
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16
Q

Delirium vs. Dementia: Onset

A

Delirium - acute (hours-days)
Dementia - chronic (months)

17
Q

Delirium vs. Dementia: Course

A

Delirium - fluctuating
Dementia - slowly progressive

18
Q

Delirium vs. Dementia: Decreased level of consciousness

A

Delirium - may be present
Dementia - absent

19
Q

Delirium vs. Dementia: Attention

A

Delirium - impaired
Dementia - preserved until end-stage

20
Q

Delirium vs. Dementia: Hallucinations

A

Delirium - common
Dementia - rare until later stages

21
Q

What are 4 strategies to help prevent delirium?

A
  1. Orientation
  2. Mobilization
  3. Medication review
  4. Hydration and nutrition
22
Q

Give examples of orientation in terms of preventing delirium (4)

A
  1. Use calendars, clocks
  2. Encourage use of glasses, hearing aids
  3. Accommodate visitors
  4. Promote regular sleep-wake cycle
23
Q

Give examples of mobilization in terms of preventing delirium (2)

A
  1. Physical therapy
  2. Avoid unnecessary lines, catheters, restraints
24
Q

Give examples of medication review in terms of preventing delirium (3)

A
  1. Reassess use of high-risk meds
  2. Medication/substance withdrawal?
  3. Pain control, bowel + bladder function
25
Q

Give examples of hydration and nutrition in terms of preventing delirium (1)

A

Maintain or optimize

26
Q

What is the hierarchy of methods to manage delirium? (3)

A

Base of the pyramid = identify and manage underlying causes
Middle = initiate or continue supportive strategies
Top = medication only if necessary

27
Q

When it comes to identifying and managing underlying cause(s) of delirium, what are some categories to be looking out for? (9)

A
  1. Readily reversible causes - e.g., hypoglycemia
  2. Infection
  3. Neurologic
  4. Medication-induced adverse effects, intentional or unintentional overdose, supratherapeutic levels because of renal or liver disease
  5. Toxicologic
  6. Metabolic
  7. Cardiopulmonary
  8. Environmental factors
  9. Other factors
28
Q

What are some examples of providing supportive care for delirium management? (7)

A
  1. Treat the underlying condition
  2. Manage pain and other symptoms
  3. Encourage mobilization
  4. Re-orientation cues
  5. Maintain sleep-wake schedule
  6. De-escalation for agitated individuals
  7. System-level interventions:
    - Minimize time spent in ER
    - Trained volunteers to calm, provide re-orientation
    - Low beds
    - Non-slip floors or socks
29
Q

We do pharmacological management of delirium ONLY IF: (3)

A
  1. The patient is in significant distress from their symptoms
  2. The patient poses a safety risk to self or others
  3. The patient is impeding essential aspects of medical care
30
Q

What is first line in pharmacological management of delirium?

A

Antipsychotics
- Similar efficacy among agents
- Choice based on side effect profile, patient factors, availability
- Start with low doses and titrate to effect ~q30min
- Prn doses thereafter

31
Q

What group of meds should be avoided in delirium management? (What is the exception)

A

Avoid benzos
- Except in alcohol-withdrawal delirium, terminal delirium

32
Q

The conventional drug of choice for delirium management is?

A

Haloperidol
- Note: if longer treatment duration is required, switch to atypical to reduce risk for EPS

33
Q

Of the atypical antipsychotics, which is most anticholinergic?

A

Olanzapine

34
Q

Which atypical AP is the agent of choice for individuals with Parkinson’s disease or Lewy Body Dementia?

A

Quetiapine

35
Q

Degree of sedation for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine

A

Haloperidol - low
Risperidone - low
Olanzapine - moderate
Quetiapine - high

36
Q

Risk of EPS for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine

A

Haloperidol - high
Risperidone - high
Olanzapine - moderate
Quetiapine - low

37
Q

Adverse effects for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine

A

Haloperidol - risk of EPS increases if daily dose exceeds 3mg
Risperidone - slightly less risk of EPS than with haloperidol at low doses
Olanzapine - more sedating than haloperidol
Quetiapine - much more sedating than haloperidol; risk of hypotension

38
Q

Atypical APs have a black-box warning for use in individuals with dementia. What is that warning?

A

Increased risk of mortality (~1.6x)
- Not seen in studies of short-term use for delirium (3-7 days)

39
Q

What is the role of the pharmacist in delirium prevention and management? (3)

A
  1. Deprescribe medications known to increase delirium risk
  2. Assess for and manage pain, constipation
  3. Ensure judicious use of antipsychotics for delirium
    - ≥25% of APs started in hospital are continued after discharge

PHAR 350 (6 decks)

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