Delirium Flashcards
Approach to delirium - what blood need?
FBC, U&E, LFTs, Bone, CRP, Ca, Glucose, TSH
CXR, ECG, Urine dip +/- MSU, Blood cultures
What is mild cognitive impairment?
Minor problem with cognition eg memory or thinling that doesnt affect their daily life but is worse than normal for their age
Precipitating factors delirium
- Medications - start/stop
- Infections
- Environmental factors
- Electrolyte abnormalities
- hypoglycaemia
- hypoxia
- Uncontrolled pain
- Urinary retention
- Faecal impaction/constipation
- Alcohol
- Srroke
- Physica restraints
- Urinary catheters
- Chest drains
Risk factors delirium
Advanced age
Pre-existing dementia
Co-morbidity - medical, depression
Post op period
Terminal illness
Sensory impairmnet - visual/hearing
Polypharmacy
Delirium pneumonic
PInCHME
Pain
Infection - chest, urine, cellulitis, venflons
Constipation
Hydration - electrolytes, NA, Ur, Calcium
Medication
Environment - change in usual, missing hearing aids/glasses, lighting
Lsit medications causing delirium
- Anitcholinergic meds - TCAs amitryptilline, oxybutynin, tolteroidine
- Furosemide, codeien, digoxin, tramadol, warfarin, nifedipine, metoclopramide
- Sedatives - benzos
- Opioid analgesics - dose
- Anti-parkinsonian drugs - LDopa, dopamine antagonists
Tests to use when concerned about delirium
4AT
CAM
Tests used for dementia
AMTS
MMSE
ACE-R MOCA etc at memory clinics
AMTS questions how many and how many is cut off
10 qs
7/8 is cut off
Questions on AMTS
1) What is your age?
2) What is the time to the nearest hour?
3) Give them an address to remember, check at the end of the test?
4) What is the year
5) What is the name of the hospital/place?
6) Can the patient recognise 2 persons?
7) What is your DOB?
8) What year did world war one begin?
9) Name the current monarch?
10) Count backwards from 20 down to 1.
What is MOCA?
MOntreal cognitive assessment
aimed at mild cognitive impariment
Delirium management
Prevention is better than cure
Non pharmacological
Pharmacological is last resort
Requires capacity asssessment - deprivation of liberty safeguards (DOLS)
Delirium prevention
Sleep - Enable good sleep patterns
Sensory impairments – ear wax, hearing aids
Nutrition – dietitian referral, dentures
Pain – assess and use evidence-base
Polypharmacy – carry out a medication review
Infection – treat any infections
Immobility – encourage them to mobilise
Hypoxia – optimise oxygen saturations
Constipation – this is vital!
Disorientation – well lit areas, reorientation devices (clocks, calendars, family members, tell them where they are)
Non pharmacological therapy
Presence of family members
Reorientation (“You’re in hospital” etc)
Remove lines and catheters where possible
Mobilise the patient
Quiet environment
Uninterrupted sleep where possible
Explain delirium to the family
Verbal and non-verbal de-escalation
Pharamcological therapy
STOP medications! (Medication review)
STOPP – Screening Tool of Older Person’s PrescriptionsSTART – Screening Tool to Alert doctors to Right Treatment
Sedation is very much a last resort, non-pharm exhausted
You must document in the notes why you are giving sedation – typically the patient is a danger to themselves, staff or other patients
