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geriatrics > Delirium > Flashcards

Delirium Flashcards

1
Q

diagnosis of delirium

A

purely clinical - no diagnostic test

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2
Q

agitated and restless delirium

A

hyperactive delirium

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3
Q

quiet and withdrawn delirium

A

hypoactive delirium

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4
Q

moving between agitated and restless, and quiet and withdrawn

A

mixed delirium

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5
Q

when to suspect delirium

A

acute/subacute change in behaviour, cognition or function
if there is a Hx of cognitive impairment/depression

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6
Q

onset of delirium

A

acute/subacute onset over hours-days

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7
Q

hallmarks of delirium

A

fluctuating symptoms (vary in intensity over the day)
decreased attention (distractible, cannot focus or shift)
altered level of consciousness (hyper alert or drowsy or unrousable)
disorganised thinking (rambling, tangential, incoherent)
altered sleep/wake cycle
perceptual disturbance
emotional deregulation (anxiety, fear, irritability)
psychomotor disturbance

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8
Q

perceptual disturbance in delirium

A

may have visual hallucination or delusions
typically persecutory, may be grandiose

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9
Q

hyperactive delirium looks like

A

30% of delirium
easier to recognise, wandering, agitated, hallucinating, aggressive, resistive to care, repetitive behaviours eg. plucking at sheets

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10
Q

hypoactive delirium looks like

A

25% of delirium
easiest to miss
appears quiet and withdrawn, drowsy, may be misdiagnosed as depressed, appears in a daze

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11
Q

mixed delirium looks like

A

45% of delirium
most common
person may switch back and forth between states

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12
Q

common times people develop delirium

A

up to a third of >65yo will develop delirium
up to 80% ICU patients
80% of patients develop delirium near death

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13
Q

consequences of delirium

A

increases mortality and morbidity
critically ill patients with delirium have more than double mortality rate compared to those who do not develop delirium
prolonged hospital LOS
increased complications and cost
increased functional decline

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14
Q

typical complications of delirium

A

malnutrition 🍎
fluid/electrolyte abnormalities 💦
infections 🦠
pressure injuries 🤕
decreased mobility (deconditioning)
falls and fractures
incontinence 🚽
wandering
discharge to residential care 🏡
long term cognition impairment

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15
Q

long term cognitive impact

A

delirium can give rise to long term cognitive impairment
may trigger onset or worsening of underlying dementia
consider referral to Memory Clinic if undiagnosed premorbid cognitive decline

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16
Q

risk factors for development of delirium

A
  1. strongest risk factor is underlying dementia
  2. depression/dysphoric mood
  3. older age, frailty, presence of multiple comorbidities, sensory impairments, male sex, alcohol misuse, past Hx of delirium
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17
Q

predisposing factors in the hospital setting that increase likelihood of developing delirium

A

use of physical restraints
malnutrition
use of urinary catheter
use of >5 medications (poly pharmacy)
any iatrogenic effect

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18
Q

can delirium be prevented through pharmacology

A

little evidence of pharmacological strategies to prevent delirium

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19
Q

delirium prevention

A

provide familiar staff
avoid room changes
orientation (clocks and calendar)
ensure glasses and hearing aids are worn
promote sleep hygiene
early mobilisation (twice daily)
cognitively stimulating activities
quiet environment esp. at night
good pain control
optimise nutrition and hydration
regulate bladder and bowel function
encourage family to be present (especially late afternoon/early evening when confusion is worse)
avoid physical restraints
minimise use of IDC
introduce yourself at every interaction

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20
Q

who should undergo screening for delirium

A

all patients on admission to hospital with one or more risk factors

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21
Q

CAM

A

confusion assessment method
for diagnosis with delirium the patient must:
display acute onset or fluctuating course AND inattention AND EITHER disorganised thinking OR altered level of aoncsciousness

22
Q

4AT

A

brief (<2 mins) standard tool for delirium detection
includes:
months backwards (attention)
alertness
AMT4 - age, DOB, place, year
scoring based on point system

23
Q

point system of the 4AT

A

greater than or equal to 4: possible delirium
1-3: possible cognitive impairment
0: delirium/severe cognitive impairment is unlikely

24
Q

reversible causes of delirium

A

medication side effects or withdrawal are the most common reversible cause
other examples: infection, hypoxia, hypo/hyperglycaemia, hypo/hyperthermia, alcohol or sedative withdrawal, anticholinergic drugs, sensory deprivation (not using glasses, hearing aids), sleep deprivation, faecal impaction, urinary retention, change of environment

25
Q

medications which can worsen cognition

A

drugs with anticholinergic effects
AED
anti-parkinson drugs
alcohol
antipsychotics
BZD
opiates
corticosteroids
cardiovascular medications (metoprolol, digoxin)

26
Q

how long does it take to recover from delirium

A

2-6 weeks

27
Q

prolonged delirium recovery

A

complete resolution can take weeks/months
can be persistent (not recover)
likely to be prolonged in the setting of an underlying dementia
can be associated with irreversible decline in physical and cognitive function

28
Q

investigations for causes of delirium

A

ECG (ischeamia, arryhtmia)
lab studies (drug screens and bacterial/viral causes)
imaging (CTB, MRI CXR as guided by clinical suspicion)

29
Q

EEG for investigation of delirium

A

if suspecting epileptic activity, non-convulsive status epilepticus (NCSE), metabolic encephalopathy or encephalitis as a cause of delirium

30
Q

who should have a CT brain

A

should not be performed routinely
indicated if new focal neurology, reduced conscious state not adequately explained by another cause, history of recent falls, head injury, on anticoagulant therapy
consider imaging patients with non-resolving delirium where no clear cause (e.g. infection) is evident or if there is suggestion of primary CNS pathology

31
Q

mainstay of delirium management

A

identify and treat cause
non-pharmacological/supportive

32
Q

when to use pharmacotherapy

A
  1. degree of agitation/aggression interferes with their ability to receive essential nursing or medical care
  2. behaviours threaten safety of self or others
  3. anxiety/delusions/hallucinations are causing significant distress
33
Q

using opiates to treat pain

A

opiates may worsen confusion but untreated pain is a cause of delirium
use lowest dose possible for adequate pain control

34
Q

best opiate to use

A

oxycodone is opiate with lowest risk of causing delirium

35
Q

worst opiate to use

A

pethidine

36
Q

drugs are not helpful for

A

calling out or wandering behaviours

37
Q

antipsychotics and BZD

A

can worsen delirium
no evidence they improve prognosis
only use if safety and care are compromised or for distressing symptoms

38
Q

when to use antipsychotics

A

only short term use of low dose
monitor for adverse effects
avoid PRN use, specify max dose in 24 hours

39
Q

examples of antipsychotics

A

haloperidol, risperidone, olanzipine, quetiapine

40
Q

choice of antipsychotic

A

olanzipine is more sedative-ish
quetiapine if Lewy body dementia or Parkinson’s
haloperidol used most commonly and can be given IM as single dose

41
Q

should you use typical or atypical antipsychotics

A

no difference typical vs. atypical in this context

42
Q

when is quetiapine the best choice

A

for patients with levy body dementia or Parkinson’s disease
causes fewer extrapyramidal symptoms

43
Q

use of melatonin

A

can help sleep wake cycle abnormalities
few side effects

44
Q

use of benzodiazepines

A

not first line
may worsen delirium
significant adverse effects
single dose may be considered if no response to antipsychotic

45
Q

possible medical adverse effects of anti-psychotic

A

sedation, postural hypotension, drug induced Parkinsonism, prolonged QTc on ECG, weight gain and hyperglycaemia, neuroepelieptic malignant syndrome
cardiovascular events, stroke and death

46
Q

does delirium require follow up

A

yes
- pts who develop delirium may have undiagnosed dementia or MCI
- possible cognitive decline following delirium
- can develop depression after delirium
- should not drive until delirium resolves

47
Q

onset of delirium vs. dementia

A

delirium: acute
dementia: insidious

48
Q

course of disease in dementia vs. delirium

A

delirium: fluctuating
dementia: progressive

49
Q

consciousness in dementia vs. delirium

A

delirium: altered
dementia: clear

50
Q

psychotic episodes in delirium vs. dementia

A

delirium: common, perceptual disturbances and auditory/visual hallucinations in up to 50%
dementia: only in late disease

51
Q

orientation in dementia vs. delirium vs. depression

A

dementia: impaired
delirium: impaired
depression: normal

geriatrics (8 decks)

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