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Ageing and Complex Health > Delirium > Flashcards

Delirium Flashcards

1
Q

What are the 4 parts of 4AT?

A
  1. Alertness
  2. AMT4
  3. Attention
  4. Acute change or fluctuating course
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2
Q

What is the scoring of alertness in 4AT?

A

Patients who are markedly drowsy (e.g. difficult to rouse and/or obviously sleep during assessment) or agitated/hyperactive. Ask patient to state their name and address to assist rating.

  • Normal (fully alert/not agitated) 0
  • Mild sleepiness for <10 secs after waking then normal 0
  • Clearly abnormal 4
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3
Q

What is the scoring of AMT4 in 4AT?

A

Age, DOB, place (name of hospital/building), current year

  • No mistakes 0
  • 1 mistake 1
  • 2 or more mistakes/untestable 2
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4
Q

What is the scoring of attention in 4AT?

A

Ask the patient to name the months in order backwards from December. Initial prompt of telling them to start at December is allowed.

  • Achieves 7 or more correctly 0
  • Starts but scores <7 months/refuses to start 1
  • Untestable (cannot start as unwell/drowsy/inattentive) 2
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5
Q

What is the scoring of acute change/fluctuating course in 4AT?

A

Evidence of significant change or fluctuation in alertness, cognition, other mental function (e.g. paranoia, hallucinations), arising over the past 2 weeks and still evident in the last 24 hours.

  • No 0
  • Yes 4
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6
Q

What does the total score of 4AT tell us?

A

4 or above: possible delirium +/- cognitive impairment
1-3: possible cognitive impairment
0: delirium or severe cognitive impairment unlikely but not ruled out

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7
Q

What is anticholinergic burden?

A

Refers to the cumulative effect of all the drugs a patient is on which possess anticholinergic effects and takes into consideration both the number of such drugs as well as the individual potencies of each drug. A score of 3+ is associated with increased cognitive impairment and mortality.

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8
Q

What are the side effects of anticholinergic drugs?

A

They have long been associated with ADRs including urinary retention, drowsiness, dry mouth and constipation.

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9
Q

What are the risk factors for delirium?

A

PINCH ME

  • Pain
  • Infection
  • Nutrition
  • Constipation (+/- urinary retention)
  • Hydration
  • Medication e.g. also electrolyte imbalances
  • Environment
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10
Q

What are the other risk factors for delirium not in the PINCH ME acronym?

A
  • Dementia (progressive cognitive decline)
  • Previous delirium episodes
  • Advancing age
  • Hip fracture
  • Polypharmacy
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11
Q

What are general measures for delirium?

A
  • Offer reassurance and try to re-orientate the patient at each opportunity - where they are, what time
  • Encourage mobility
  • Try to promote normal sleep-wake cycle e.g. stop nocturnal interventions, keep lights off
  • Encourage oral intake of food and fluids (e.g. missing dentures)
  • Regulation of bladder and bowel function
  • Minimise sensory impairment by getting their glasses/hearing aids
  • Encourage family/friends to visit and help support re-orientation and reassurance
  • Review medications/check for withdrawal
  • Pain control
  • Prevention, early identification and treatment of postoperative complications
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12
Q

What is the Confusion Assessment Method (CAM)?

A

Delirium is likely to be present if there is:
1. Presence of acute confusion, with fluctuation
AND
2. Inattention (difficulty concentrating)
AND EITHER
3. Disorganised thinking
OR
4. Altered level of consciousness i.e. heightened arousal/agitation or drowsy

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13
Q

In what circumstances can pharmacological therapy be considered for delirium?

A
  • To prevent the patient endangering themselves or others
  • To allow staff to carry out essential investigations or treatment
  • To relieve stress in highly agitated patients, particularly those with paranoia or hallucinations
  • Non-pharamacological measures have failed
  • The patient should have their capacity assessed as to whether they are agreeable to sedation
  • DoLS should be completed at this stage if they do not have capacity to consent for sedation
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14
Q

What are the contraindications for haloperidol?

A
  • QTc interval on the ECG
  • Parkinson’s
  • Lewy Body dementia
  • Hx of Torsade de pointes, ventricular arrhythmia or recent cardiac event (MI or decompensated HF)
  • Cannot be used alongside any medication that causes prolonged QT interval
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15
Q

What are the contraindications for risperidone?

A
  • Parkinson’s
  • Lewy Body Dementia
  • Can cause prolongation of QTc interval so ECG should be done prior to ensure it is normal
  • This is off licence for delirium
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16
Q

What are the contraindications for lorazepam?

A
  • Risk of respiratory depression
  • Falls
  • Deliriumogenic
  • Exercise caution in renal impairment
  • Off licence for delirium
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17
Q

What is the pharmacological treatment for delirium?

A

1st line: low dose haloperidol short-term (1 week or less) - 0.5-1mg PO (max 2mg/24hr)
2nd line: low dose lorazepam if haloperidol contraindicated

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18
Q

Which tools should be used for detecting delirium in different settings?

A
  • 4-AT tool should be used in A+E, acute hospital settings and the community
  • In intensive care settings CAM-ICU or ICDSU should be considered to help identify possible delirium.
19
Q

When should a CT head be done in delirium?

A
  • New focal neurological signs
  • A reduced level of consciousness (not adequately explained by another cause)
  • A hx of recurrent falls
  • A head injury (patients of any age)
  • Anticoagulation therapy
20
Q

When should an EEG be done in delirium?

A

When there is suspicion of epileptic activity or non-convulsive status epilepticus as a cause of a patient’s delirium.

21
Q

What are the non-pharmacological stages for delirium treatment?

A
  1. Consider acute life threatening causes e.g. low O2, low BP, low glucose, drug/alcohol intoxication/withdrawal
  2. Identify and treat potential causes e.g. medications
  3. Management of concurrent conditions, environment (reduce noise), medications, sleep
  4. Detect, asses causes of and treat agitation +/or distress
  5. Communicate diagnosis to family/carers and encourage involvement
  6. Aim to prevent complications e.g. immobility, falls, isolation
  7. Monitor for recovery consider specialist referral
  8. Consider follow-up
22
Q

What are the 5 overarching principles of the Mental Capacity Act (2005) and DoLS?

A
  1. A person is assumed to have capacity unless it is established they do not
  2. A person is not to be treated as unable to make a decision unless all steps to help him have been taken without success
  3. A person is not to be treated as unable to make a decision merely because they make an unwise one
  4. An act/decision on behalf of a person who lacks capacity must be done in their best interests
  5. Before the act is done/decision made, regard must be had to whether the purpose for it being needed can be effectively achieved in a way that is least restrictive of the person’s rights/freedom
23
Q

How do you assess capacity?

A
  1. Is there an impairment of, or a disturbance in the functioning of, the mind or brain?
  2. The Act states that someone lacks the capacity to make a specific decision if the answer to 1 is yes and they are unable to do 1 or more of the following:
    - Understand the info relevant to the decision
    - Retain that information
    - Use or weigh up that information as part of the process of making the decision
    - Communicate their decision
24
Q

What are commonly missed causes of delirium?

A
  • Urinary retention
  • Constipation
  • Pain
25
Q

What is hyperactive delirium?

A

Patients appear restless and agitated. They may be aggressive and appear to have a heightened state of arousal. They may exhibit non-purposeful walking and have insomnia.

26
Q

What is hypoactive delirium?

A

Patients are often drowsy and withdrawn. They may display somnolence. This is the most under-recognised subtype and carries the highest risk of subsequent death.

27
Q

What is mixed delirium?

A

Patients have features of both hyperactive and hypoactive delirium and cycle between the 2 states.

28
Q

What happens if delirium persists?

A

Most patients will recover over days to months but some will never completely recover back to their previous level of cognitive functioning. These patients should be referred to appropriate services for follow-up and to explore the possibility of a dementia diagnosis.

29
Q

What investigations will help to find a cause for delirium?

A
  • Plasma glucose
  • FBC
  • U+E’s, LFTs, TFTs, bone profile
  • CRP
  • ECG
  • CXR
  • Examinations - DRE, bladder palpation (urine hx)
  • Fluid balance
  • Obs
30
Q

Why are UTIs often misdiagnosed?

A

They can be misdiagnosed as positive on a urine dip due to the presence of asymptomatic bacteriuria in older people.

31
Q

Why is constipation common among hospital patients?

A
  • Reduced mobility
  • Addition of constipating medications
  • Dehydration
32
Q

What are the secondary causes of constipation?

A
  • Iron or calcium supplements
  • Analgesics - opiates, NSAIDs
  • Antidepressants - TCAs, antipsychotics
  • Antiepileptics - carbamazepine, gabapentin
  • Antihistamines
  • Diuretics
  • Diabetes
  • Hypercalcaemia and hyperparathyroidism
  • Hypokalaemia
  • Hypothyroidism
33
Q

What is the non-pharmacological management of constipation?

A
  • Eat healthy, balanced diet and regular meals - whole grains, fruits, veg
  • Fibre intake increased gradually (to minimise flatulence and bloating) - aim for 3g/day
  • Adequate fluid intake
  • Increase activity and exercise levels
  • Prescription review: stop medications causing/contributing to symptoms
34
Q

What is 1st line treatment for constipation?

A

Bulk forming laxative e.g. ispaghula

Advise to gradually reduce and stop laxatives once producing soft, formed stool without straining at least 3x/week

35
Q

What is 2nd line treatment for constipation?

A

Osmotic laxative e.g. macrogol, then offer lactulose if macrogol ineffective or not tolerated

36
Q

What treatment should be used for opioid-induced constipation?

A

Osmotic and stimulant laxative (or docusate)

37
Q

What is the treatment for chronic constipation?

A
  1. 1st and 2nd line treatment of constipation
  2. If stools are soft but difficult to pass or sensation of inadequate emptying, add a stimulant laxative
  3. Consider prucalopride if at least 2 different laxatives from different classes tried at highest tolerated recommended doses for at least 6 months and failed to relieve symptoms.
38
Q

What are bulk-forming laxatives?

A

They contain soluble fibres which result in increased fluid retention within the stool and hence increase the overall faecal mass as well as stimulating peristalsis. Important to have adequate fluid intake also. Examples are ispaghula husk.
SE’s: flatulence and bloating

39
Q

What are osmotic laxatives?

A

Work by increasing the amount of fluid within the large bowel either through drawing fluid into the bowel or by holding onto of the fluid it is co-administered with. The result is stimulation of peristalsis. Examples are macrogols and lactulose.

40
Q

What are stimulant laxatives?

A

Stimulate peristalsis. Examples are senna, biscodyl and sodium picosulfate.
SE’s: abdominal cramping and contraindicated in intestinal obstruction

41
Q

What are faecal softeners?

A

Increase fluid content and reduce the surface tension of the stool and thus allow to mass more easily. Examples are glycerol and sodium docusate (latter also contains stimulant properties).

42
Q

What are the features of delirium?

A
  • Visual hallucinations
  • Restlessness/agitation/combative behaviour
  • Calling out/making sounds
  • Quiet and withdrawn
  • Slowed movement and lethargy
  • Disturbed sleep
  • Disorientated to time and place
  • Hypodelirium - drowsy, hand movements
43
Q

How is delirium different to dementia?

A
  • Impairment of consciousness
  • Acute fluctuation of symptoms: worse at night, periods of normality
  • Abnormal perception (e.g. illusions and hallucinations) - comes later in dementia
  • Agitation, fear
  • Delusions

Ageing and Complex Health (11 decks)

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