D - Delirium for Ageing

Question 1

What is delirium (acute alteration in mental state which indicates an underlying condition) defined as?

Answer 1

Delirium is a disturbance in attention that is associated with a change in cognition that develops over a short period of time and tends to fluctuate during the day

Question 2

Mortality rates of delirium are high as it is often misdiagnosed What percentage of adults in nursing homes will have delirium?

Answer 2

Over 10% of residents in nursing homes will have delirium

Question 3

What does delirium mean for in regards to a patients hospital stay?

Answer 3

Usually increases the duration of the stay and there tends to be more complications

Question 4

What condition predisposes to delirium and vice versa?

Answer 4

Dementia makes delirium occurring more likely and vice versa It is therefore a vicious cycle

Question 5

State the function of the medication and potential side effects

Answer 5

Aspirin - anti-platelet for the history of TIAs - can cause GI bleeds and worsen heart failure and kidney function Simvastatin - lower cholseterol - can cause muscle pain Bendroflumethiazide - anti-hypertensive agent - can cause hypokalaemia and hyponatraemia, gout and hyperglycaemia Co-codamol - used for the pain in OA - constipation&sedative Citalopram - used to treat depression - sedatory effect Levothyroxine - used to treat underactive thyroid Tolterodine - used to treat an overactive bladder - sedatory

Question 6

Incontinency of urine can lead to delirium What is likely to have caused the incontinency?

Answer 6

The co-codamol can cause constipation which can lead to incontinency

Question 7

Should a urine dipstick be carried out and why?

Answer 7

Dont dipstick urine in the elderly as it a a false positive for urinalysis, Also dont dipstick in catheterised patients

Question 8

What are the hallmark features of delirium?

Answer 8

Acute and fluctuation change in cognition Innatention Altered level of consciousness and disorganied thinking

Question 9

How does the onset of dementia, depression and delirium differ?

Answer 9

Dementia - gradual over months/years and progressive Depression - occurs over at least a couple of weeks and is reversible with treatment Delirium - usually occurs over hours to days and is reversible

Question 10

What is a key hallmark feature of dementia?

Answer 10

Word finding difficulties is a key feature

Question 11

What are the different types of delirium? Define delirium again

Answer 11

Hyperactive which accounts for 30% Hypoactive delirium which accounts for 50% Mixed which accounts for the further 20% Delirium is defined as the acute disturbance in attention accompanied by a change in cognition that tend to develop over a short period of time and fluctuate throughout the day

Question 12

How does hyperactive delirium differ from hypoactive?

Answer 12

Hyperactive - agitated and restless Hypoactive - sleepy/drowsy and slow

Question 13

Does hallucinations occur in dementia or delirium or depression?

Answer 13

Normally late stages in dementia apart from Lewy Body dementia It is more common in deliriium Only occurs in severe cases of depression

Question 14

how does this differ from delirium and depression?

Answer 14

Delirium is acute occuring over hours to days an is reversible Usually people can be hyperalert or hypoactive and have fluctuating emotions Depression occurs over a few weeks and people tend to be withdrawn, worse in the mornings- reversible with treatment

Question 15

The pathophysiology of delirium is not well understood What is the key neurotransmitter involved believed to be and which drug classes present as a high risk?

Answer 15

Acetlycholine is believed to be involved Benzodiazpeines are believed to be a cause

Question 16

What are the predisposing risk factors to delirium?

Answer 16

Advanced age Pre-exsitng dementia Sensory impairments Depression Alcohol dependency Malnutrition Urinary incontinence Polypharmacy

Question 17

What are the hallmark features of delirium again?

Answer 17

Acute change in cognition and fluctuation throughout the day Inattention Disorganised think Altered level of consciousness

Question 18

Which type of delirium has the higher mortality rate?

Answer 18

Hypoactive - withdrawn, apethetic, sleep - this has the higher mortality rate as it is easy to misdiagnose - twice the mortality rate of hyperactive Hyperactive - agitated, restless, agressive

Question 19

What are the two tests used in the diagnosis of delirium?

Answer 19

The 4AT - assessment test for delirium and cognitive impairment - gold standard The CAM - confusion assessment method

Question 20

What are the 4 components of the 4AT test?

Answer 20

Alertness AMT4 - abbreviated mental test 4 Attention Acute change or fluctuating course

Question 21

If the patients alertness is clearly abnormal, what is their score? What is asked in the AMT4?

Answer 21

Their score would be 4 for alertness Ask their age, date of birth, location and what the current year is

Question 22

What is asked for attention? What does their need to be evidence of in the acute change or fluctuating course to get the score of 4? (other score is 0)

Answer 22

Ask the patient to count back the months from december Needs to have evidence of change or fluctuation in alertness, cognition or other mental function ie hallucinations arising over last 2 weeks and evident in last 24 hours

Question 23

Score of 4 or above on the 4 AT means what? Score of 1-3 means what? Score of 0 means what?

Answer 23

4 or above - possible delirium +/- cognitive impairment 1-3 - posssible cognitive impairment 0 - unlikely to be cognitively impaired or delirium but delirium still possible if the acute change or fluctuation course is incomplete

Question 24

Again what are the 4 sections of the 4AT and what is asked?

Answer 24

1. Alertness - if clearly abnormal then 4 2. AMT4 (abbreviated mental test 4) - age, dob, location and current year 3. Attention - ask patient to recite months from december backwards 4. Acute change or fluctuating course - in alertness, cognition, other mental function eg hallucinations

Question 25

What do the final scores in the 4AT test mean again?

Answer 25

Score of 0 - unlikely to be cognitively impaired or delirium - still can be delirium if information for acute change or fluctuating course info incomplete Score of 1-3 - possible cognitive impairment Score of 4 or more - possible delirium +/- cognitive impairment

Question 26

How sensitive and how specific is the 4AT test for delirium?

Answer 26

89.7 (90) % sensitivity and 84.1 (84) % specific for delirium

Question 27

What are the 4 aspects of the confusion assessment method?

Answer 27

1. Acute change in mental status And 2. Inattention - easily distracted And 3. Disorganized speech (rambling) or 4. Altered level of consciousness - hyperalert/irrtable or dowsy/sleepy

Question 28

What test can be used to detect inattention?

Answer 28

The digit span test can be used or Can ask patient to count the months backwards

Question 29

What are the 4 parts of the 4AT? What are the 4 parts of the CAM?

Answer 29

4AT (the 4A’s Test) 1. Alertness 2. AMT4 - abbreviated mental state test 3. Innatention 4. Acute change or fluctuating course CAM - Confusion assessment method 1. Acute change in mental status or fluctuating status throughout the day 2. Innatention 3. Disorganized thinking (rambling) or 4. Altered level of consciousness - hyperactive, hypoactive

Question 30

if the patient has delirium, what is the checklist to follow to find the cause?

Answer 30

Check bloods - electrolytes and glucose Ensure good hydration septic screen Check for and correct hypoxia ECG for MI/arrythmia Stop drugs with nuerotoxic effects Relieve pain Avoid a urinary catheter unless in retention Treat consitpation Think about alcohol withdrawal

Question 31

Again state what the checklist to find the cause of the delirium is?

Answer 31

Check bloods - electrolytes and glucose Ensure good hydration Septic screen Check for and correct hypoxia ECG for MI and arrythmia Stop neurotxic drugs Relieve pain Avoid catheter unless retetnion Think about alcohol withdrawal

Question 32

What are the side effects of anti-cholinergic drugs which can predispose to delirium? (also a risk factor for falls) (ABCDS)

Answer 32

• Agitation
• Blurred vision - can make falls more likely
• Constipation - predisposes to UTI
• Confusion - delirium
• Dry mouth
• Stasis of urine/sweating - UTI risk - delirium risk

Question 33

What are the good general measures and environment measures for a person delirium?

Answer 33

Lightly lit room Clock where easy to see Avoid loud hospital areas - probs put in side room Ensure a buzzer is close by

Question 34

Use non-pharmacological measures where possible When is the only time to prescribe a patient with a sedative?

Answer 34

Only if the patient is a harm to themselves or others

Question 35

Which drug is generally first line in delirium if the patient requires it?

Answer 35

This would be haloperidol 0.25mg - anti-psychotic medication

Question 36

What drug is given in alcohol withdrawal causing delirium or if the patient has parkinsons?

Answer 36

Would give a benzodiazepine (chlordiazepoxide or diazepam) - for alcohol induced or benzodiazepine withdrawal or Quetiapine if the patient has Lewy body dementia or parkinsons also (quetiapine works less on the dopamine channels than haloperidol as it is an atypical, therefore doesnt exacerbate symptoms of DLB or DPD as much) - usually second line to Lorazepam in these patients ALWAYS DOCUMENT WHY SEDATION IS GIVEN