Delerium

Question 1

what is delerium?

Answer 1

“Delirium is a state of mental confusion that starts suddenly and is caused by a physical condition of some sort.

You don’t know where you are, what time it is, or what’s happening to you. It is also called an ‘acute confusional state’.”

Question 2

4AT score

Answer 2

1. alertness (normal, mild sleepiness, clearly abnormal)
2. AMT4 age, DOB, place, current year. no mistake, 1 mistake, >2 mistakes

3. attention
tell me months of the year in backwards order
>7 months correct
<7 months
untestable

4. acute change / fluctiation
   evidence of significant change or fluctuation in alert, cognition, mental function in last 2 weeks and still evident in last 24 hours

> 4 possible delirium and cog impairment
1-3 possible cog impairment
0 delerium or severe cognitive impairment is unlikely.

Question 3

features of delirium

Answer 3

• alerted consciousness
• disorganised features
• psychomotor (picking at bed sheets ‘carphology’
• altered perception (hallucination, paranoia)
• emotional disturbance (aggression, tearfulness)

Question 4

who is at risk of delirium

Answer 4

Older (>65 years)
Cognitive impairment
Current hip fracture
Severe illness
Up to half of all medical admissions in older people have delirium

Question 5

prevention of delirium

Answer 5

Hearing & vision
Nutrition & dentures
Maximise sleep
Lighting
Signage
Hydration
Bowel care

Regular orientation
Medication review
Assess & manage pain
Avoid catheter/ cannula
Cognitive stimulation
Facilitate family visits
Early mobilisation

Question 6

investigations for delirium

Answer 6

bedside:
NEWS / vitals
pain score
urinalysis

bloods:
FBC, U+E, CRP, glucose, culture, bone, thyroid, liver

meds review and alcohol history

physical exam, rectal

Question 7

medications that can cause delirium

Answer 7

any brain active meds

• opiates
• epilepsy and parkinson meds
• TCA
• benzo’s
• anticholinergic side effects: bladder drugs like oxybutinin
• steroids

Question 8

pneumonic for causes of delirium

I WATCHED DEATH

Answer 8

Infection
Withdrawl (alcohol, sedatives)
Acute metabolic (acidosis/alkalosis)
Trauma (closed head injury, haematoma)
CNS pathology
Hypoxia
Deficiencies (thiamine, niacin, b12, folate)
Endocrinopathies (thyroid, glucose, adrenal)
Acute vascular (hypertensive crisis, arrhythmia)
Toxins/drugs
Heavy metals

Question 9

delerium vs dementia

Answer 9

delirium:

• transient global disorder of cognition
• acute onset (days/weeks)
• reduced/variable LOC
• reversible

dementia:

• global impairment of memory, personality, cognition, functionality
• chronic and progressive
• in clear consciousness
• irreversible

Question 10

hypoactive delirium

Answer 10

carries a worse prognosis
more likely to be missed by staff
symptoms- drowsy, lethargy, apathy, slowing of speech

Question 11

hyperactive delerium

Answer 11

tends to be better diagnosed
motor symptoms
symptoms- agitation, restlessness, agression

Question 12

mixed delerium

Answer 12

combination of hyperactive and hypoactive

Question 13

risk factors for delerium

Answer 13

non modifiable
>65 y/o
cognitive impairment
current hip fracutre
severe illness

modifiable
polypharmacy
procedures/iatrogenic
pharmacological restaint

Question 14

triggers for delerium

Answer 14

“PINCH ME”

pain
infection
nutrition
constipatin
hydration/hypoxia/hypoglycaemia
medication
electrolyte/environment

Question 15

pneumonic for delerium

Answer 15

DELERIUM
PINCH ME
I WATCHED DEATH
CHIMPS PHONED

Question 16

delirium examination

Answer 16

neuro: GCS, CN, power, sensation, tone, reflex, cerebellar

resp: IPPA
CVS, murmur, oedema, JVP, MM?
abdo: urinary retention, pain, jaundice
legs: oedema, pain, swelling

PR exam

Question 17

“CONFUSION SCREEN”

Answer 17

bloods:
FBC, U+E, LFT, CRP, Ca2+, BM, glucose, b12/folate

urine dip
ECG
bladder scan
CXR
CT

rare- LP, colonoscopy, enodscopy

Question 18

worsening urinary incontinence

Answer 18

possible causes:
untreated UTI
dementia
poor mobility
medications (diuretics)

investigations
U+E
MSU
urine cytology
USS of KUB
flexible cystoscopy

Question 19

management of urinary incontinence

Answer 19

simple:
incontinence pads
review meds
treat any underlying infection (Atrophic vaginitis)

anticholinergics
surgical correction
long term catheterisation

Question 20

what are the four geriatric giants

Answer 20

falls
confusion
incontinence
impaired homeostasis
iatrogenic disorders

Question 21

types of incontinence

Answer 21

stress
urge
overflow
functional

Question 22

stress incontinence

Answer 22

loss of small volumes of urine with increase in intra abdominal pressure (laughing/coughing) caused by bladder outflow tract and pelvic floor weakness. usually needs surgical corection

Question 23

urge incontinece

Answer 23

detrusor muscle instability
can be associated with local urogenital disease (cystitis, urethritis, tumors) or neurological conditions (dementia, CVA, spinal cord compression)

Question 24

overflow incontinence

Answer 24

mechanical pressures on the bladder outflow tract causing urinary retention

e. g. obstruction - prostatic enlargement, urethral stricture, tumors
e. g. neuropathic bladder: diabetes, MS, spinal cord compression

Question 25

functional incontinence

Answer 25

inability to reach toilet through physical or cognitive impairment
e.g. confusional states, arthritis, depression, meds.

Question 26

other causes of confusion

Answer 26

cerebral hypoxia
hypoglycaemia
sepsis/toxins
anaesthetic/drugs
head injury

Question 27

evaluating confusion

Answer 27

neuro (GCS)
withdrawl
determine O2 saturation
low BP and UO
fever, tachycardia
neck stiffness