Delirium Flashcards
diagnosis of delirium
purely clinical - no diagnostic test
agitated and restless delirium
hyperactive delirium
quiet and withdrawn delirium
hypoactive delirium
moving between agitated and restless, and quiet and withdrawn
mixed delirium
when to suspect delirium
acute/subacute change in behaviour, cognition or function
if there is a Hx of cognitive impairment/depression
onset of delirium
acute/subacute onset over hours-days
hallmarks of delirium
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
perceptual disturbance in delirium
may have visual hallucination or delusions
typically persecutory, may be grandiose
hyperactive delirium looks like
30% of delirium
easier to recognise, wandering, agitated, hallucinating, aggressive, resistive to care, repetitive behaviours eg. plucking at sheets
hypoactive delirium looks like
25% of delirium
easiest to miss
appears quiet and withdrawn, drowsy, may be misdiagnosed as depressed, appears in a daze
mixed delirium looks like
45% of delirium
most common
person may switch back and forth between states
common times people develop delirium
up to a third of >65yo will develop delirium
up to 80% ICU patients
80% of patients develop delirium near death
consequences of delirium
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
typical complications of delirium
malnutrition 🍎
fluid/electrolyte abnormalities 💦
infections 🦠
pressure injuries 🤕
decreased mobility (deconditioning)
falls and fractures
incontinence 🚽
wandering
discharge to residential care 🏡
long term cognition impairment
long term cognitive impact
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
risk factors for development of delirium
- strongest risk factor is underlying dementia
- depression/dysphoric mood
- older age, frailty, presence of multiple comorbidities, sensory impairments, male sex, alcohol misuse, past Hx of delirium
predisposing factors in the hospital setting that increase likelihood of developing delirium
use of physical restraints
malnutrition
use of urinary catheter
use of >5 medications (poly pharmacy)
any iatrogenic effect
can delirium be prevented through pharmacology
little evidence of pharmacological strategies to prevent delirium
delirium prevention
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
who should undergo screening for delirium
all patients on admission to hospital with one or more risk factors
CAM
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
4AT
brief (<2 mins) standard tool for delirium detection
includes:
months backwards (attention)
alertness
AMT4 - age, DOB, place, year
scoring based on point system
point system of the 4AT
greater than or equal to 4: possible delirium
1-3: possible cognitive impairment
0: delirium/severe cognitive impairment is unlikely
reversible causes of delirium
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
medications which can worsen cognition
drugs with anticholinergic effects
AED
anti-parkinson drugs
alcohol
antipsychotics
BZD
opiates
corticosteroids
cardiovascular medications (metoprolol, digoxin)
how long does it take to recover from delirium
2-6 weeks
prolonged delirium recovery
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
investigations for causes of delirium
ECG (ischeamia, arryhtmia)
lab studies (drug screens and bacterial/viral causes)
imaging (CTB, MRI CXR as guided by clinical suspicion)
EEG for investigation of delirium
if suspecting epileptic activity, non-convulsive status epilepticus (NCSE), metabolic encephalopathy or encephalitis as a cause of delirium
who should have a CT brain
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
mainstay of delirium management
identify and treat cause
non-pharmacological/supportive
when to use pharmacotherapy
- degree of agitation/aggression interferes with their ability to receive essential nursing or medical care
- behaviours threaten safety of self or others
- anxiety/delusions/hallucinations are causing significant distress
using opiates to treat pain
opiates may worsen confusion but untreated pain is a cause of delirium
use lowest dose possible for adequate pain control
best opiate to use
oxycodone is opiate with lowest risk of causing delirium
worst opiate to use
pethidine
drugs are not helpful for
calling out or wandering behaviours
antipsychotics and BZD
can worsen delirium
no evidence they improve prognosis
only use if safety and care are compromised or for distressing symptoms
when to use antipsychotics
only short term use of low dose
monitor for adverse effects
avoid PRN use, specify max dose in 24 hours
examples of antipsychotics
haloperidol, risperidone, olanzipine, quetiapine
choice of antipsychotic
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
should you use typical or atypical antipsychotics
no difference typical vs. atypical in this context
when is quetiapine the best choice
for patients with levy body dementia or Parkinson’s disease
causes fewer extrapyramidal symptoms
use of melatonin
can help sleep wake cycle abnormalities
few side effects
use of benzodiazepines
not first line
may worsen delirium
significant adverse effects
single dose may be considered if no response to antipsychotic
possible medical adverse effects of anti-psychotic
sedation, postural hypotension, drug induced Parkinsonism, prolonged QTc on ECG, weight gain and hyperglycaemia, neuroepelieptic malignant syndrome
cardiovascular events, stroke and death
does delirium require follow up
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
onset of delirium vs. dementia
delirium: acute
dementia: insidious
course of disease in dementia vs. delirium
delirium: fluctuating
dementia: progressive
consciousness in dementia vs. delirium
delirium: altered
dementia: clear
psychotic episodes in delirium vs. dementia
delirium: common, perceptual disturbances and auditory/visual hallucinations in up to 50%
dementia: only in late disease
orientation in dementia vs. delirium vs. depression
dementia: impaired
delirium: impaired
depression: normal
