Confusion and Delirium

Question 1

____ assessment is used to screen for delirium. What is the criteria?

Answer 1

CAM assessment

• acute onset and fluctuating in course
• inattention
• disorganized thinking
• altered level of consciousness

Question 2

___ is a rapid test for delirium: what 4 aspects of it does it take into consideration?

Answer 2

4AT:

1. alertness
2. age, DOB, place, current year (no mistakes, 1 mistake, 2 or more mistakes)
3. attention
4. acute change or fluctuating course

*note: a positive screen does not equal diagnosis. You must rule out imitators and find evidence that there are underlying medical conditions.

Question 3

Prevention of Delirium: Multicomponent intervention

Answer 3

Cognitive stimulation, orientation

Non-pharmacological sleep protocols: try to allow for patients’ sleep cycles, minimize medical procedures during sleep, encourage activity during the day.

Early and regular mobility

Sensory optimization

Hydration and nutrition

ARR of 5.1%

Review and avoid high risk medications: avoid new psychoactive meds, start low, go slow when necessary, beware of withdrawal effects of certain medications.

Reduce iatrogenic risk: watch for complications regarding the urinary catheters and physical restraints

Watch for fluid and electrolyte imbalance: frequent volume assessment and appropriate treatment.

Pain control: regularly scheduled acetaminophen, NSAIDs, low dose narcotics if ongoing

Encourage family and caregiver presence, use translators when available

Watch for and treat hypoxia with adequate oxygenation.

Question 4

Treatment/Management of Delirium

• treatment when agitated?

Answer 4

Antipsychotics, antidepressants, severity of delirium

Address unmet needs: toileting, hunger, discomfort.

When aggressive/agitated

• First line is non-pharmacological approach
• Second line: trial low dose of atypical antipsychotics
• Risperidone, olanzapine.25 PO bid or daily
• Haloperidol 0.5mg IM

Question 5

Describe the morbidity and mortality associated with delirium in older adults and recognize delirium as a medical emergency.

Answer 5

Consequences of Delirium

• Increases functional decline, discharge to institution, cognitive impairment, risk of mortality, length of stay in hospital
• Increases falls and hospital acquired complications
• Expensive; iatrogenic complications (falls/fractures/ pressure ulcers, PNA)

Delirium is a Medical Emergency

• May be the only symptom of an underlying illness
• RR 1-3 year mortality for MI is 1.42 in men → mortality is high

Question 6

Name two validated screening tools for delirium.

Answer 6

CAM

Do not need to perform an MMSE

Can do mental reversal tasks, digit span, vigilance A, interview/exam tests.

4AT test

Question 7

2 Subtypes of Delirium: Which one has a higher mortality?

Answer 7

Hyperactive: agitated, restless, likely resists care

Hypoactive: Somnolent, quiet, passive, much less likely to be detected, higher mortality.

Generally, Delirium is:

A disturbance in attention that is a change from baseline attention and awareness

Develops over hours to days and fluctuates in severity

Additional change in cognition

Not better explained by another neurocognitive disorder

evidence that it is caused from general medical condition/substance

*there are no biomarkers for diagnosing delirium.

Question 8

Biomarkers for diagnosing delirium

Answer 8

*there are no biomarkers for diagnosing delirium.

Question 9

An MMSE score below ___ is a predisposing factor for delirium. What lab value is a predisposing factor?

Answer 9

• Sensory impairment (vision, hearing)
• Cognitive impairment (MMSE<24)
• Older age
• High co-morbidity count
• High risk medication use
• Functional impairment
• High urea to Cr ratio

Question 10

Outline the DIMS mechanism for a precipitating factor

Answer 10

Precipitating Factors: DIMS!! (drugs/dehydration, iatrogenic/infection/inflammatory, medications/metabolic, structural/stroke),

Acute medical illnesses

Use of physical restraints

Malnutrition

>3 new medications

Urinary catheters

Any iatrogenic event

Question 11

Select appropriate investigations, interventions and management strategies to prevent and treat delirium.

Answer 11

DIMS investigations: drug list (OTC, prescribed, recreational), lytes panel (metabolic and dehydration assessment), culture panel and CBC (infection– meningitis, oral infection, abdominal, joint, skin), ECG/EKG (heart ischemic), CT (Brain ischemia and stroke and mass), urine analysis, physical exams.