Delerium Flashcards
Delerium Overview
Common
Medical emergency
increases risk for other adverse outcomes
Quiet Delirium (Hypoactive)
Avoids making eye contact Doesn't know loved ones Doesn't know where they are Visual/Audio hallucinations Slurred speech Slow to answer
Excited Delirium (Hyperactive)
Restlessness Attempts to get up Fearfulness Aggressive behavior Physical attacks on caregiver Throwing objects Disorientation Not recognizing caregiver
Delirium DSM V
Disturbed consciousness Cognitive changes Rapid onset (hrs to days) or Fluctuating daily course Evidence of causal physical conditions 3 types: hypoactive, hyperactive, mixed
CAM assessment
- Acute onset or fluctuating course
- Inattention
- Disorganized thinking
- Altered LOC
Dx of Delirium = presence of 1 and 2 and either 3 or 4
Risk Factors
Dementia
Advanced age
Other Comorbid conditions: Sleep deprivation, pain, immobility, dehydration, sensory impairment
Common Causes
Meds
Infection - UTI, PNA, ingrown toenail
Metabolic disorders - Na+ imbalance, hypercalcemia
CV - CP, Acute MI
Neuro - CVA, ICH, seizure disorder
Renal
Endocrine - hypothyroid, hypo/yperglycemia
Misc. - fecal impaction, sleep deprivation, Post-op states, pain
Meds that can cause Delirium (ACUTE CHANGE IN MS)
Antiparkinson’s drugs (also think Alcohol withdrawal)
Corticosteriods
Urinary incontinence drugs
Theophylline
Emptying drugs (metoclopramine, compazine)
Cardiovascular drugs (clonidine, digoxin, some antiarrthymics)
H 2 blockers (especially for persons with renal disease –cimetidine, ranitidine
Antibiotics (case reports – quinolones)
NSAIDs (case reports)
Geropsychiatry drugs (most in class are centrally acting) acute toxicity and withdrawal
ENT drugs (antihistamines, Meclizine, Scopolamine, anticholinergics)
Insomnia drugs (Benadryl – dipenhydramine, OTCs, TCAs)
Narcotics (Demerol not recommended)
Muscle relaxants (centrally acting)
Seizure drugs
Anticholinergic Burden
Be conscious of drugs that are added onto med list and the combined anticholinergic effects
Differential Dx (DELIRIUMS)
Drugs Eyes, ears Low oxygen states (MI, stroke, PE) Infection Retention (of urine or stool) Ictal (post seizure) Underhydration/undernutrition Metabolic (hyperglycemia, hyponatremia, ARF) (S)ubdural – acute brain injury
Delirium vs Dementia
Consciousness Orientation Course Onset Attention Psychomotor Hallucinations Sleep-Wake Speech
Derlirum - hypo/hyper alert, clouded, disorganized, fluctuating course, acute/subacute onset, Impaired attention, psychomotor agitated or lethargic, may have hallucinations, sleep-wake cycle abnrml, slow, incoherent speech
Dementia - alert, disoriented, slow and steady decline, chronic, attn usual normal, psychomotor usually nrml, hallucinations usually not present, sleep-wake cycle usually nrml, speech: aphasic, anomic, difficulty word-finding
Eval
Assume reversibility until proven otherwise
Consider med list - last new med added, OTCs
R/O infection
Labs to consider
CBC, Lytes, Renal fxn, LFT, Albumin, Ca++, Glucose, Ammonia, UA, UDS O2 sat CXR, ECG CT, EEG - if suspicious of CVA, seizures
Management
Ensure safety
Elicit family help as sitters
Remove causal meds
Tx underlying causes
Targeted Interventions to Prevent Delirium (PREVENT)
Protocol for sleep- back massage, relaxation music, decreased noise, warm milk, or caffeine-free herbal tea
Replenish fluids and recognize volume depletion
Ear aides – amplifier or hearing aid
Visual aids- glasses, magnifying lens
Exercise or ambulation
Name person, place and time frequently for reorientation (when appropriate)
Taper or discontinue unnecessary medications. Use alternative and less harmful medications.
