Delirium Flashcards
What is Delirium?
- An acute confusional state that causes disturbed consciousness, cognition, attention and perception
What are the characteristic features of Delirium?
- Acute onset (hours to days)
- Fluctuating symptoms (alters throughout the day)
- Disturbance in awareness and attention (reduced awareness, distractible)
- Disturbance in cognition ( memory, language & disorientation)
- Evidence of an organic cause (medical condition, medication and intoxication)
What is the Classification of Delirium?
- Hyperactive Delirium: inappropriate behaviour, agitation or hallucinations, wandering and restlessness
- Hypoactive Delirium: reduced activity, patients appear quiet, lethargic, withdrawn and have reduced concentration
- Mixed Delirium: hypoactive and hyperactive features
What are the causes of Delirium?
- Neurological ( brain injury, subdural haematoma, stroke, Cerebrovascular disease)
- Cardiovascular (heart failure, MI, Atrial Fibrillation)
- Respiratory (aspiration, pneumonia, Exacerbation of COPD)
- GI (constipation, malnutrition, bleeding)
- Urological (urinary retention, UTI)
- Skin & Joints (cellulitis, Pressure sores)
- Metabolic/ Endocrine (thyroid disease, hypo/hyperglycaemia, hypo/hypernatraemia)
- Medications (anti-histamines, TCA, anti-cholinergics
- Other (alcohol, uncontrolled pain, Sleep deprivation, change in environment, hearing impairment)
What are the Risk Factors of Delirium?
- Age >65
- Multiple co-morbidities
- Frailty
- Malnutrition
- Sensory impairment (hearing and vision)
- Functional impairment
- Alcohol Excess
- Major injury
- Cognitive impairment
What is the Pathophysiology in Delirium?
- Global cortical dysfunction
- One of the main dominant mechanisms is abnormal neurotransmitters in the brain
- This includes reduced levels or acetylcholine or increased levels of dopamine
- Therefore worse with anti-cholinergic medications (oxybutynin)
What is the treatment of Delirium relating to increase in dopamine?
- Haloperidol (anti-dopaminergic medications)
What are the clinical features of Delirium?
- Disturbances in consciousness and cognitive function
- Suspect in sudden change in behaviour
- Delirium is typically acute onset and fluctuates throughout the course of the day
- UTI and Constipation make it worse
- Abnormal consciousness, Abnormal cognition, abnormal thinking, abnormal perception, Other features
What are the features of Abnormal consciousness?
- Reduced level of awareness and focus
- Drowsy or semicomatose
- Hyperactive
What are the features of Abnormal cognition?
- Memory loss, Disorientation (to place, person and time), Poor language (loss ability to speak a second language), Poor speech
What are the features of Abnormal thinking?
- Distractible and inattention (unable to follow commands)
- Disorganised thinking (poor flow of ideas, disorganised speech, unable to express their needs)
What are the features of Abnormal Perception?
- Visual/ Auditory Hallucinations
- Paranoid delusions
- Misperception
What are the Other Features regarding Delirium?
- Labile changes in mood (irritable, paranoid, fear and depression)
- Agitation
- Sleep-cycle disturbances
- Hypersensitivities (light/sound)
How do you make a diagnosis of Delirium?
- DSM-5 criteria (A. A disturbance in attention and awareness, B. Acute onset and fluctuating, C. Other cognitive disturbances D. No other neurocognitive disorder present E. evidence this is an organic cause
- Cognitive Assessment: Confusion Assessment method, The 4A’s test, Abbreviated Mental test
What is the DSM-5 Criteria?
- Disturbance in awareness ( disorientated to time, place and person) and attention
- Acute onset (hours to days), acute change from baseline and fluctuant
- Disturbance in cognition (memory loss, misperception)
- Not better explained by pre-existing, established, or evolving neurocognitive disorder and absence of severely reduced GCS
- Evidence of an organic cause (medical condition, medication, intoxication)
What is CAM (confusion Assessment method)?
- Acute & Fluctuating course
- Inattention
- Disorganised thinking
- Altered level of consciousness
Diagnosis: 1 and 2 plus either 3 or 4
Time <5 mins
Hospital or Community
What is the 4A’s test?
- Alertness
- AMT questions: age, DOB, place, current year
- Attention: list months in reverse order starting with December
- Acute change or fluctuating course
Time <5 mins
Setting: hospital
Score (1-3 dementia, 4-12 dementia/ delirium)
What is an AMT?
- A ten item scoring tool predominantly used in hospital settings
- Time <5 minutes
- Setting: hospital and GP
- Cut-off for delirium (6-7/10)
What Bedside Investigations would you consider?
- Obs
- ECG
- Cultures: Sputum, Urine, Stool
- Capillary Blood Glucose
What bloods would you do for Delirium ?
- FBC
- U&E
- LFTS
- Bone Profile
- Calcium
-HA1c - Haematinics: Vit B12, Folate
- TFTs
- CRP
- Drug Levels
- Syphilis Serology
What Imaging would you do for Delirium ?
- Chest X-ray
- CT head
-ECHO
What is the management for Delirium ?
- Mental Capacity Assessment
- Treat underlying cause (antibiotics for infection, laxatives for constipation)
- Deescalation methods:
1. Address underlying cause of behaviour ( infection, drugs, constipation, urinary retention, dehydration + electrolyte imbalance, Pain and sensory impairment)
2. Optimize treatment of co-morbidities: COPD, Dementia, DM, Heart Failure, Thyroid disease, Parkinson’s disease, CVS disease
3. Consider moving to a safe, low-stimulant environment
4. Use non-threatening verbal and non-verbal techniques
5. Involve relatives or carers who are close to the patient (1. Try reorientation strategies- explain to the patient where they are, make clocks easily visible, encourage visits from friends and family, 2. Maintain safe mobility - encourage walking 3. Normalise the sleep-wake cycle = discourage napping and encourage bright light exposure
6. Consider involvement of geriatricians and local delirium/ dementia team
Rapid Transquillisation:
1. 0.5mg Haloperidol first line sedative
2. If the patient has Parkinsons = 1. Reduce Parkinson’s medication 2. Use of Atypical medication = Quetiapine and Clozapine
What is the prognosis for Delirium?
- An episode of delirium may take weeks to months
- older patients have an increased risk of having prolonged delirium with adverse outcomes
- delirium accelerates cognitive decline after and episode of delirium
What are the main differences between Delirium and Dementia?
Sleep-wake Cycle: Dementia = normal, Delirium = reversed
Attention: Dementia = normal, Delirium = significant inattention and lack of concentration
Duration: Dementia = months to years, Delirium = days to weeks
Delusions: Dementia = none, Delirium = may experience
Course: Dementia = progressive, Delirium = fluctuating
Conscious level: Dementia = normal, Delirium = altered
Hallucinations: Dementia = none, Delirium = may experience
Rate of Onset: Dementia: Months to years, Delirium = hours to days
Psychomotor Activity: Dementia = not usually present, Delirium = hyperactive or hypoactive
What the 5 P’s of delirium?
- PAIN
- PEE = UTI
- PILLS = Medications
- POO = constipation
- PUS = infection
What is the best tool to assess cognition for Delirium?
- CAM ( The confusion Assessment Method)
What is involved in a CAM assessment?
- Acute Onset/ Fluctuating Course
- Inattention
- Disoragnised thinking
- Altered Level of Consciousness
( Requires the presence of features 1 and 2 and 3 or 4)
What Act should be used if a patient with Delirium wants to leave hospital?
- Mental Capacity Act 2005
