Delerium Flashcards
What is cognitive impairment?
Cognitive Impairment – disturbance of higher cortical functions including memory, thinking, judgement, language, perception, and awareness.
Always important to look for an underlying cause of any acute fluctuation of cognitive ability. Often there is a treatable cause. Always compare behaviour to the patient’s baseline.
What is delerium?
Delirium is organically caused, sudden state of severe confusion and rapid changes in brain function expressed as over or under activity and often has a fluctuating course. Usually has a psychomotor element and with a disturbed sleep/wake cycle. Fluctuates throughout the day and is usually worse at night.
What are the core features of delerium?
Cognitive Impairment
Rapid onset
Fluctuating severity
What are the risk factors for delerium?
Age >65 Dementia Previous cognitive impairment Hip fracture Acute illness and co-morbidities Psychological agitation e.g. pain Functional impairment Sensory impairment Polypharmacy
How does delerium present?
Globally impaired cognition, perception and consciousness that fluctuates
Develops over hours/days
Memory deficit
Disordered or disorientated thinking
Reversal of the sleep wake cycle
Hallucinations and illusions – seeing something that is there but in the wrong way
What are the three types of delerium?
Hyperactive – restlessness, mood lability, agitation or aggression
Hypoactive – slow and withdrawn (higher risk of mortality due to lack of mobilising)
Mixed
List some common causes of delerium
Surgery/post GA
Systemic infections such as UTI, pneumonia, malaria and IV lines
Intracranial infection or head injury
Drugs/drug withdrawal. Psychoactive drugs such as antidepressants, antipsychotics and benzos, Anticholinergic drugs, opiates, levodopa or recreational
Alcohol withdrawal
Metabolic – uraemic or liver failure
Constipation
Hypoxia from respiratory or cardiac failure
Vascular – stroke or MI
Nutritional – thiamine, nicotinic acid or B12 deficiency
Dehydration
What differentials should always be considered before diagnosing delerium?
Depression, dementia, anxiety, epilepsy, and primary mental illness such as schizophrenia
What questionnaires can be used to assess for delerium?
Short Confusion Assessment Method (short CAM)
1. Acute onset and fluctuating course
2. Inattention – squeeze my hand when I say the letter A – repeat many letters
3. Disorganised thinking – do stones float, are fish in the sea, does 1lb weigh more than 2lb, can you use a hammer to pound a nail?
4. Altered level of consciousness – V, P or U
1 and 2 plus 3 or 4 for a diagnosis of delirium.
Abbreviated mental Test Score (AMT) Does the patient know their age? Does the patient know their DoB? Does the patient know where they are? Does the patient know what year it is? 1 mark for each correct answer if <4 then high risk of delirium
What investigations should be undertaken in suspected delerium?
FBC, U&E (especially calcium), LFTs, Blood glucose, ABG and Septic screen including urine dip CRP B12 and Folate Collateral History CXR if indicated
How can you assess for pain in non verbal demeted patients?
Assessing for Pain in Non-verbal demeted patient
Abbey pain scale
- vocalisation - whimpering
- facial expression - grimacing
- body language - rocking/guarding
- behavioural changes
- physiological changes - BP/tempterature
- physical changes - skin tears/ulcers
How can you assess for ADLs in frail populations?
Assessing ADLs in Frail Population
Katz-ADL score:
- Transferring
- Toileting
- Bathing
- Dressing
- Feeding
- Continence
- Mobility
How should you managed/prevent delerium?
Continuity of care – avoid moving people a lot and changing stuff
Keep communicating about where they are and why and what is going on
Keep well hydrated and address constipation
Optimise oxygen saturation
Encourage movement and prevent immobility
Address pain
Keep good sleep pattern
Avoid catheters, cannulas,
Review medications and discontinue anything that is not necessary
Make sure they have access to their glasses and/or hearing aids
If sedation is required for a patient with reduced cognitive function what should you use?
If sedation is required (last resort) then use antipsychotics (haloperidol or olanzapine unless Parkinson’s) over benzos (Lorazepam) as they tend to worsen delirium.
What are the long term complications of delirium?
Increased length of stay
Increased mortality
Increased rate of institutionalisation
Increased chance of readmission
