D - Delirium for Ageing Flashcards
What is delirium (acute alteration in mental state which indicates an underlying condition) defined as?
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
Mortality rates of delirium are high as it is often misdiagnosed What percentage of adults in nursing homes will have delirium?
Over 10% of residents in nursing homes will have delirium
What does delirium mean for in regards to a patients hospital stay?
Usually increases the duration of the stay and there tends to be more complications
What condition predisposes to delirium and vice versa?
Dementia makes delirium occurring more likely and vice versa It is therefore a vicious cycle
State the function of the medication and potential side effects
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
Incontinency of urine can lead to delirium What is likely to have caused the incontinency?
The co-codamol can cause constipation which can lead to incontinency
Should a urine dipstick be carried out and why?
Dont dipstick urine in the elderly as it a a false positive for urinalysis, Also dont dipstick in catheterised patients
What are the hallmark features of delirium?
Acute and fluctuation change in cognition Innatention Altered level of consciousness and disorganied thinking
How does the onset of dementia, depression and delirium differ?
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
What is a key hallmark feature of dementia?
Word finding difficulties is a key feature
What are the different types of delirium? Define delirium again
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
How does hyperactive delirium differ from hypoactive?
Hyperactive - agitated and restless Hypoactive - sleepy/drowsy and slow
Does hallucinations occur in dementia or delirium or depression?
Normally late stages in dementia apart from Lewy Body dementia It is more common in deliriium Only occurs in severe cases of depression
how does this differ from delirium and depression?
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
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?
Acetlycholine is believed to be involved Benzodiazpeines are believed to be a cause
What are the predisposing risk factors to delirium?
Advanced age Pre-exsitng dementia Sensory impairments Depression Alcohol dependency Malnutrition Urinary incontinence Polypharmacy
What are the hallmark features of delirium again?
Acute change in cognition and fluctuation throughout the day Inattention Disorganised think Altered level of consciousness
Which type of delirium has the higher mortality rate?
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
What are the two tests used in the diagnosis of delirium?
The 4AT - assessment test for delirium and cognitive impairment - gold standard The CAM - confusion assessment method
What are the 4 components of the 4AT test?
Alertness AMT4 - abbreviated mental test 4 Attention Acute change or fluctuating course
If the patients alertness is clearly abnormal, what is their score? What is asked in the AMT4?
Their score would be 4 for alertness Ask their age, date of birth, location and what the current year is
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)
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
Score of 4 or above on the 4 AT means what? Score of 1-3 means what? Score of 0 means what?
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
Again what are the 4 sections of the 4AT and what is asked?
- 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
What do the final scores in the 4AT test mean again?
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
How sensitive and how specific is the 4AT test for delirium?
89.7 (90) % sensitivity and 84.1 (84) % specific for delirium
What are the 4 aspects of the confusion assessment method?
- 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
What test can be used to detect inattention?
The digit span test can be used or Can ask patient to count the months backwards
What are the 4 parts of the 4AT? What are the 4 parts of the CAM?
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
if the patient has delirium, what is the checklist to follow to find the cause?
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
Again state what the checklist to find the cause of the delirium is?
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
What are the side effects of anti-cholinergic drugs which can predispose to delirium? (also a risk factor for falls) (ABCDS)
- Agitation
- Blurred vision - can make falls more likely
- Constipation - predisposes to UTI
- Confusion - delirium
- Dry mouth
- Stasis of urine/sweating - UTI risk - delirium risk
What are the good general measures and environment measures for a person delirium?
Lightly lit room Clock where easy to see Avoid loud hospital areas - probs put in side room Ensure a buzzer is close by
Use non-pharmacological measures where possible When is the only time to prescribe a patient with a sedative?
Only if the patient is a harm to themselves or others
Which drug is generally first line in delirium if the patient requires it?
This would be haloperidol 0.25mg - anti-psychotic medication
What drug is given in alcohol withdrawal causing delirium or if the patient has parkinsons?
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
