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OPIC > Delirium > Flashcards

Delirium Flashcards

1
Q

What is Delirium?

A
  • An acute confusional state that causes disturbed consciousness, cognition, attention and perception
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2
Q

What are the characteristic features of Delirium?

A
  • 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)
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3
Q

What is the Classification of Delirium?

A
  • 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  • Hypoactive Delirium: reduced activity, patients appear quiet, lethargic, withdrawn and have reduced concentration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
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4
Q

What are the causes of Delirium?

A
  • 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)
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5
Q

What are the Risk Factors of Delirium?

A
  • Age >65
  • Multiple co-morbidities
  • Frailty
  • Malnutrition
  • Sensory impairment (hearing and vision)
  • Functional impairment
  • Alcohol Excess
  • Major injury
  • Cognitive impairment
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6
Q

What is the Pathophysiology in Delirium?

A
  • 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)
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7
Q

What is the treatment of Delirium relating to increase in dopamine?

A
  • Haloperidol (anti-dopaminergic medications)
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8
Q

What are the clinical features of Delirium?

A
  • 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
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9
Q

What are the features of Abnormal consciousness?

A
  • Reduced level of awareness and focus
  • Drowsy or semicomatose
  • Hyperactive
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10
Q

What are the features of Abnormal cognition?

A
  • Memory loss, Disorientation (to place, person and time), Poor language (loss ability to speak a second language), Poor speech
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11
Q

What are the features of Abnormal thinking?

A
  • Distractible and inattention (unable to follow commands)
  • Disorganised thinking (poor flow of ideas, disorganised speech, unable to express their needs)
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12
Q

What are the features of Abnormal Perception?

A
  • Visual/ Auditory Hallucinations
  • Paranoid delusions
  • Misperception
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13
Q

What are the Other Features regarding Delirium?

A
  • Labile changes in mood (irritable, paranoid, fear and depression)
  • Agitation
  • Sleep-cycle disturbances
  • Hypersensitivities (light/sound)
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14
Q

How do you make a diagnosis of Delirium?

A
  • 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
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15
Q

What is the DSM-5 Criteria?

A
  1. Disturbance in awareness ( disorientated to time, place and person) and attention
  2. Acute onset (hours to days), acute change from baseline and fluctuant
  3. Disturbance in cognition (memory loss, misperception)
  4. Not better explained by pre-existing, established, or evolving neurocognitive disorder and absence of severely reduced GCS
  5. Evidence of an organic cause (medical condition, medication, intoxication)
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16
Q

What is CAM (confusion Assessment method)?

A
  1. Acute & Fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Altered level of consciousness

Diagnosis: 1 and 2 plus either 3 or 4
Time <5 mins
Hospital or Community

17
Q

What is the 4A’s test?

A
  1. Alertness
  2. AMT questions: age, DOB, place, current year
  3. Attention: list months in reverse order starting with December
  4. Acute change or fluctuating course

Time <5 mins
Setting: hospital
Score (1-3 dementia, 4-12 dementia/ delirium)

18
Q

What is an AMT?

A
  • A ten item scoring tool predominantly used in hospital settings
  • Time <5 minutes
  • Setting: hospital and GP
  • Cut-off for delirium (6-7/10)
19
Q

What Bedside Investigations would you consider?

A
  • Obs
  • ECG
  • Cultures: Sputum, Urine, Stool
  • Capillary Blood Glucose
20
Q

What bloods would you do for Delirium ?

A
  • FBC
  • U&E
  • LFTS
  • Bone Profile
  • Calcium
    -HA1c
  • Haematinics: Vit B12, Folate
  • TFTs
  • CRP
  • Drug Levels
  • Syphilis Serology
21
Q

What Imaging would you do for Delirium ?

A
  • Chest X-ray
  • CT head
    -ECHO
22
Q

What is the management for Delirium ?

A
  • 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
23
Q

What is the prognosis for Delirium?

A
  • 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
24
Q

What are the main differences between Delirium and Dementia?

A

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

25
Q

What the 5 P’s of delirium?

A
  • PAIN
  • PEE = UTI
  • PILLS = Medications
  • POO = constipation
  • PUS = infection
26
Q

What is the best tool to assess cognition for Delirium?

A
  • CAM ( The confusion Assessment Method)
27
Q

What is involved in a CAM assessment?

A
  1. Acute Onset/ Fluctuating Course
  2. Inattention
  3. Disoragnised thinking
  4. Altered Level of Consciousness

( Requires the presence of features 1 and 2 and 3 or 4)

28
Q

What Act should be used if a patient with Delirium wants to leave hospital?

A
  • Mental Capacity Act 2005

OPIC (18 decks)

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