Cognitive Impairment (Delirium) Flashcards
What is delirium according to the DSM-5? (4)
- Acute onset
- Disturbances in attention, awareness, and cognition
- Fluctuates in severity
- Attributable to an underlying cause
Delirium is an _____ ___________ state
acute confusional
What are 3 other features of delirium?
- Psychomotor disturbance
- Altered sleep-wake cycle
- Emotional lability
What is the significance of delirium? (4)
- Poor prognostic indicator
- 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 - Increased length of hospitalization (5-10 days)
- Sustained functional decline 6 months after admission
What underlying vulnerabilities can cause delirium? (4)
- Cognitive dysfunction
- Frailty
- Age
- Stressor(s)
- Hypoxia
- Infection
- Drugs
- Pain
- Hypoglycemia
- Dehydration
What are some predisposing factors of delirium? (5)
- Increased age
- Dementia
- Functional impairment (baseline)
- Multimorbidity
- Others
- Decreased vision and/or hearing
- Mild cognitive impairment
- Depression
- Alcohol or drug use/withdrawal
What are some precipitating factors of delirium? (7)
- DRUGS
- Surgery/trauma
- Pain
- Anemia
- Infection
- Exacerbation of chronic illness
- Bedridden
What are the worst drugs in terms of causing delirium? (3 groups)
- Anticholinergics
- TCAs
- 1st gen antihistamines
- 1st gen antipsychotics
- Muscle relaxants
- Antimuscarinics
- Benztropine - BZDs/Z-Drugs
- Opioids
What are the bad, but not worst drugs in terms of causing delirium? (4 groups)
- Anticonvulsants
- Carbamazepine
- Phenytoin
- Topiramate
- Gabapentin/pregabalin - Dopamine agonists
- Amantadine
- Cannabis (THC/dose-related)
What drugs are less likely but can still possibly cause delirium? (4)
- Corticosteroids
- Psychoactive NSAIDs
- Digoxin
- Cannabis (CBD-based)
What is the most useful bedside tool used for diagnosing delirium?
Confusion Assessment Method (CAM)
The confusion assessment method (CAM) requires 1+2 with either 3 or 4. List 1 through 4 symptoms on the list
- Acute change in mental status with fluctuations
- Inattention
- Disorganized thinking
- Altered level of consciousness
What are the 3 delirium subtypes?
- Hyperactive delirium
- Mixed delirium
- Hypoactive delirium
What are the general symptoms of hyperactive delirium? (3)
- Combative
- Agitated
- Restless
What are the general symptoms of hypoactive delirium? (3)
- Drowsy
- Somnolent
- Unarousable
Delirium vs. Dementia: Onset
Delirium - acute (hours-days)
Dementia - chronic (months)
Delirium vs. Dementia: Course
Delirium - fluctuating
Dementia - slowly progressive
Delirium vs. Dementia: Decreased level of consciousness
Delirium - may be present
Dementia - absent
Delirium vs. Dementia: Attention
Delirium - impaired
Dementia - preserved until end-stage
Delirium vs. Dementia: Hallucinations
Delirium - common
Dementia - rare until later stages
What are 4 strategies to help prevent delirium?
- Orientation
- Mobilization
- Medication review
- Hydration and nutrition
Give examples of orientation in terms of preventing delirium (4)
- Use calendars, clocks
- Encourage use of glasses, hearing aids
- Accommodate visitors
- Promote regular sleep-wake cycle
Give examples of mobilization in terms of preventing delirium (2)
- Physical therapy
- Avoid unnecessary lines, catheters, restraints
Give examples of medication review in terms of preventing delirium (3)
- Reassess use of high-risk meds
- Medication/substance withdrawal?
- Pain control, bowel + bladder function
Give examples of hydration and nutrition in terms of preventing delirium (1)
Maintain or optimize
What is the hierarchy of methods to manage delirium? (3)
Base of the pyramid = identify and manage underlying causes
Middle = initiate or continue supportive strategies
Top = medication only if necessary
When it comes to identifying and managing underlying cause(s) of delirium, what are some categories to be looking out for? (9)
- Readily reversible causes - e.g., hypoglycemia
- Infection
- Neurologic
- Medication-induced adverse effects, intentional or unintentional overdose, supratherapeutic levels because of renal or liver disease
- Toxicologic
- Metabolic
- Cardiopulmonary
- Environmental factors
- Other factors
What are some examples of providing supportive care for delirium management? (7)
- Treat the underlying condition
- Manage pain and other symptoms
- Encourage mobilization
- Re-orientation cues
- Maintain sleep-wake schedule
- De-escalation for agitated individuals
- System-level interventions:
- Minimize time spent in ER
- Trained volunteers to calm, provide re-orientation
- Low beds
- Non-slip floors or socks
We do pharmacological management of delirium ONLY IF: (3)
- The patient is in significant distress from their symptoms
- The patient poses a safety risk to self or others
- The patient is impeding essential aspects of medical care
What is first line in pharmacological management of delirium?
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
What group of meds should be avoided in delirium management? (What is the exception)
Avoid benzos
- Except in alcohol-withdrawal delirium, terminal delirium
The conventional drug of choice for delirium management is?
Haloperidol
- Note: if longer treatment duration is required, switch to atypical to reduce risk for EPS
Of the atypical antipsychotics, which is most anticholinergic?
Olanzapine
Which atypical AP is the agent of choice for individuals with Parkinson’s disease or Lewy Body Dementia?
Quetiapine
Degree of sedation for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine
Haloperidol - low
Risperidone - low
Olanzapine - moderate
Quetiapine - high
Risk of EPS for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine
Haloperidol - high
Risperidone - high
Olanzapine - moderate
Quetiapine - low
Adverse effects for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine
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
Atypical APs have a black-box warning for use in individuals with dementia. What is that warning?
Increased risk of mortality (~1.6x)
- Not seen in studies of short-term use for delirium (3-7 days)
What is the role of the pharmacist in delirium prevention and management? (3)
- Deprescribe medications known to increase delirium risk
- Assess for and manage pain, constipation
- Ensure judicious use of antipsychotics for delirium
- ≥25% of APs started in hospital are continued after discharge
