Confusion

Question 1

In the event that a confused elderly patient cannot give a full history who should you get a collateral history from?

Answer 1

Their carer, general practitioner or any source with good knowledge of the patient

Question 2

What tool can be used to quickly aid in the diagnosis of delirium?

Answer 2

the confusion assessment method

Question 3

True or false only psychiatric-ally trained clinicians can use the confusion assessment method?

Answer 3

False

Question 4

What is the first and most important action for the treatment of delirium?

Answer 4

Identification and treatment of the underlying cause

Question 5

What special measures nursing wise need to be made for a patient with delirium.

Answer 5

A good sensory environment with a reality orientation approach and with the involvement of a multi-disciplinary team

Question 6

How frequently should a delirious patient’s patient’s medication be reviewed?

Answer 6

At least once daily

Question 7

What is the one drug recommended for treating delirium?

Answer 7

Haloperidol

Question 8

How should Haloperidol be administered?

Answer 8

Starting at the lowest possible dose then increasing in increments if necessary every 2 hours. One to one care should be provided while the drug is titrated up to a safe controlled dose

Question 9

In what proportion of cases can delirium be prevented?

Answer 9

one third

Question 10

What risks are posed to a patient with delirium compared to non delirious patients?

Answer 10

increased mortality, length of stay, complication and institutionalization rates.

Question 11

What proportion of older patients in the emergency department have delirium

Answer 11

one in seven

Question 12

what proportion of older patients develop delirium after hip fractures.

Answer 12

43-61%

Question 13

Over what period of time do the symptoms of delirium precipitate?

Answer 13

Hours or days

Question 14

What are the predisposing factors for delirium

Answer 14

Old age, severe illness, dementia, physical frailty, admision with dehydration or infectio, visual/hearing impairment, polypharmy, surgery (e.g. fractured neck of femur) Alcohol excess, renal impairment.

Question 15

What are the precipitating factors for delirium?

Answer 15

Immobility, use of physical restraint, use of urinary catheter, iatrogeny (e.g. general anesthesia), malnutrition, psychoactive medications, inter-current illness, dehydration, benzodiazepine or alcohol withdraw

Question 16

What is the typical pattern one sees in delirium symptoms throughout the day?

Answer 16

Diurnal pattern (worse at night)

Question 17

What four features allow one to make the diagnosis of dementia?

Answer 17

Acute onset, Disturbance of consciousness, impaired cognition or perceptual disturbance not due to preexisting dementia, clinical evidence of an acute general medical condition such as intoxication or substance withdraw

Question 18

what are the two main patterns of delirium according to the ICD?

Answer 18

hyperactive delirium (agitated and wandering) and hypoactive delirium (quiet and withdrawn)

Question 19

What extra concern needs to be taken with hypoactive delirium?

Answer 19

that it doesn’t get overlooked or get misdiagnosed as a mood disorder

Question 20

What does the differential diagnosis of delirium include?

Answer 20

dementia, depression, hysteria, mania, schizophrenia, dysphasia, seizures

Question 21

What types of seizures can be a differential for delirium?

Answer 21

temporal lobe and non convulsive status epilepticus

Question 22

What four common drug groups can cause delirium in older people?

Answer 22

opioid analgesics, drugs with anticholinergic properties, sedating drugs, corticosteroids

Question 23

What environmental factors can be modified to prevent delirium?

Answer 23

avoiding overstimulation, ensure the patient is not deprived of spectacles or hearing aids and providing environmental and personal orientation

Question 24

Apart from environmental factors what nine measures can be taken to prevent and manage delirium?

Answer 24

Minimize discontinuity of care, encourage mobility, reduce medicines where possible (while maintaining adequate analgesia, maintain adequate fluid intake and nutrition, maintain normal sleep patern, avoid constipation, involve relatives and carers, ensure regular medical, nursing and therapy reviews

Question 25

How often is no underlying cause of delirium found? What is more often than not the explanation for this?

Answer 25

up to a fifth. Delirium can persist longer than the underlying cause so it may resolve itself before discovery.

Question 26

what are the main complications of delirium?

Answer 26

Falls, pressure sores, hospital acquired infections, functional impairment, incontinence, over sedation, malnutrition

Question 27

What are the 10 common causes of delirium?

Answer 27

infection, acute hypoxaemia, electrolyte imbalance, prescribed medicines, myocardial infarction, alcohol or benzodiazepine withdrawal, urinary retention, fecal impaction, neurological (stroke, subdural haematoma, seizures) and post operative cognitive dysfunction.

Question 28

What are the 11 first line investigations for delirium?

Answer 28

Full blood count, C reactive protein, urea and electrolytes, calcium, thyroid function tests, glucose, chest x-ray, electrocardiogram, pulse oximetry, urinalysis

Question 29

What are the four second line investigations for delirium?

Answer 29

ABGs, brain CT, EEG and specific culture swabs e.g. wound swab, sputum blood or CS fluid.

Question 30

What are the four components of treating delirium?

Answer 30

Treatment of the underlying cause, environmental measures, pharmacological measures, prevention of complications