Delerium Flashcards

1
Q

Define delerium

A

The rapid onset (over hours or days) with fluctuating symptoms of

  1. Altered level of consciousness with inattention, and
  2. A change in cognition (memory deficit, disorientation, language disturbance), or development of perceptual disturbance (hallucination)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is hyperactive delirium?

A

Agitation and hypervigilance e.g. Irene

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is hypoactive delirium?

A

Quiet and withdrawn, hypoalert (worse prognosis, because it is missed more often)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the main differences between delirium and dementia?

A

Differences between dementia and delirium

  1. Onset of dementia is gradual, over months to years rather than hours to days in delirium
  2. Dementia has a progressive course, rather than a fluctuating in delirium
  3. Altered level of attention and consciousness in delirium
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

List the predisposing factors of delirium.

A

These factors are MULTIPLICATIVE
• Advanced age - have mild/moderate risk of delirium due to associations with below
• Impaired cognition (delirium, previous ABI, disability)
• Previous Hx of delirium
• Depression
• Functional disability or functional dependence (lack of dependence) including immobility
• Dehydration
• Psychoactive drugs
• Visual and hearing impairment
• Chronic co-morbidity
- Dementia - delirium is closely linked to dementia, each is a RF for the other and they often co-exist * the biggest risk factor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

List the precipitating factors of delirium.

A
• Drugs
• Primary neurological diseases
• Inter-current illness
• Surgery
• Unfavourable environmental factors - in dwelling catheters
• Sleep deprivation
• Malnourishment
5-10% of elderly patients will develop delirium as an in patient especially at aged care facilities, palliative care, orthogeriatrics, ICU
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the causes of delirium?

A

• Physical: infection (UTI, respiratory, cellulitis), pain, constipation
• Metabolic: hypoxia, hypo/hyperglycaemia, electrolyte disturbance
- Drug related: alcohol or drug withdrawal, anticholinergics, antidepressants, analgesic, antipsychotics (benzos)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Pathogenesis of delirium

A

Unknown pathogenesis, but reduced cerebral oxidative metabolism causing altered neurotransmitter levels in prefrontal and subcortical areas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

DDx of delirium

A

• Depression
• Anxiety
• Psychosis
- Dementia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Ix if suspecting delirium

A

If the person NQR (not quite right), it is delirium until proven otherwise.

  1. Bedside: Review drug chart thoroughly for drug related delirium for anticholinergics, antidepressants, analgesic, antipsychotics (benzos) withdrawals particularly from benzos and alcohol
  2. Bloods: CRP, WCC, electrolytes (hypo/hypernatraemia), glucose, oxygen
  3. Path: urine dipstick, swab and culture obvious sites - in dwelling catheter, cannula site
  4. Imaging: CXR, CT brain if Hx of fall with headstrike, anticoagulated, active malignancy, photophobia or neck stiffness
  5. Other: ECG

DO MMSE and CAM (confusion assessment score).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Diagnosis criteria of delirium

A

Diagnosis requires 1, 2 and either 3 or 4:

  1. Acute onset and fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Altered level of consciousness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Prevention of delirium

A

• Use glasses or hearing aids to reduce sensory impairment
• Offered adequate food and fluids
• O2 supplementation if indicated
- Minimise sleep disturbance (avoid nursing procedures, reduce noise during sleep hours)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Non pharmacological Mx of delirium

A

• Mainstay treatment is nurse and carer based, only use drugs after non -drug measures have failed
• Treat underlying condition (see Causes)
○ Medications with CNS effects may precipitate and/or aggravate delirium, where possible withdraw slowly, over a few days
• Supportive care
○ Mobilise as much as possible
○ Maintain nutrition and fluid levels
○ Access to day light, then low stimulus at night
○ Family member visits
○ Education for the family
○ Repeatedly reorientating: explain where they are, who they are and what your role is
○ Put in hearing aids, glasses, removing wax
Do not physically restrain is it may aggravate agitation leading to falls and injuries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

When do you use drug Mx for delirium?

A

Only consider drug treatment of anti-psychotics if
• Impacting on their own treatment
• Threatens others or self
• Anxiety, delusions or hallucinations cause significant distress to themselves
• Anti-psychotics: best evidence for haloperidol - readily available, easy to titrate (olanzepine has anti-cholingergic effect, so therefore do not use)
Short term only, low dose - extra pyramidal side effects

Melatonin can be used to normalise the sleep wake cycle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is first line for withdrawal related delirium?

A

Benzodiazepines.

NB only secondary in Mx of non-withdrawal delirium as it can aggravate the patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Complications of delirium

A

• 12 mth mortality is 35-40%
• Persistent delirium: Median duration of delirium is app 1 week, but often when discharged they still have features of delirium
Advise families: patients can get better, but they will not necessarily get 100% better
• Hypoactive: pressure sores, DVT, pneumonia
• Hyperactive: falls
• Increase length of hospital stay
• Nutrition declines - inability to open packaging and eat
Depression and PTSD