Delerium Flashcards
what is delerium?
“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’.”
4AT score
- alertness (normal, mild sleepiness, clearly abnormal)
- 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
- 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.
features of delirium
- alerted consciousness
- disorganised features
- psychomotor (picking at bed sheets ‘carphology’
- altered perception (hallucination, paranoia)
- emotional disturbance (aggression, tearfulness)
who is at risk of delirium
Older (>65 years) Cognitive impairment Current hip fracture Severe illness Up to half of all medical admissions in older people have delirium
prevention of delirium
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
investigations for delirium
bedside:
NEWS / vitals
pain score
urinalysis
bloods:
FBC, U+E, CRP, glucose, culture, bone, thyroid, liver
meds review and alcohol history
physical exam, rectal
medications that can cause delirium
any brain active meds
- opiates
- epilepsy and parkinson meds
- TCA
- benzo’s
- anticholinergic side effects: bladder drugs like oxybutinin
- steroids
pneumonic for causes of delirium
I WATCHED DEATH
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
delerium vs dementia
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
hypoactive delirium
carries a worse prognosis
more likely to be missed by staff
symptoms- drowsy, lethargy, apathy, slowing of speech
hyperactive delerium
tends to be better diagnosed
motor symptoms
symptoms- agitation, restlessness, agression
mixed delerium
combination of hyperactive and hypoactive
risk factors for delerium
non modifiable >65 y/o cognitive impairment current hip fracutre severe illness
modifiable
polypharmacy
procedures/iatrogenic
pharmacological restaint
triggers for delerium
“PINCH ME”
pain infection nutrition constipatin hydration/hypoxia/hypoglycaemia medication electrolyte/environment
pneumonic for delerium
DELERIUM
PINCH ME
I WATCHED DEATH
CHIMPS PHONED
delirium examination
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
“CONFUSION SCREEN”
bloods:
FBC, U+E, LFT, CRP, Ca2+, BM, glucose, b12/folate
urine dip ECG bladder scan CXR CT
rare- LP, colonoscopy, enodscopy
worsening urinary incontinence
possible causes: untreated UTI dementia poor mobility medications (diuretics)
investigations U+E MSU urine cytology USS of KUB flexible cystoscopy
management of urinary incontinence
simple:
incontinence pads
review meds
treat any underlying infection (Atrophic vaginitis)
anticholinergics
surgical correction
long term catheterisation
what are the four geriatric giants
falls confusion incontinence impaired homeostasis iatrogenic disorders
types of incontinence
stress
urge
overflow
functional
stress incontinence
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
urge incontinece
detrusor muscle instability
can be associated with local urogenital disease (cystitis, urethritis, tumors) or neurological conditions (dementia, CVA, spinal cord compression)
overflow incontinence
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
functional incontinence
inability to reach toilet through physical or cognitive impairment
e.g. confusional states, arthritis, depression, meds.
other causes of confusion
cerebral hypoxia hypoglycaemia sepsis/toxins anaesthetic/drugs head injury
evaluating confusion
neuro (GCS) withdrawl determine O2 saturation low BP and UO fever, tachycardia neck stiffness
