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Yr 4 - Psychiatry > Delirium > Flashcards

Delirium Flashcards

1
Q

What is delirium?

A

A common and serious clinical syndrome characterised by a disturbance of attention which is ACUTE in onset and is FLUCTUATING.

There is an additional disturbance of cognition such as memory, orientation or perception.

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2
Q

What is the DSM 5 criteria for delirium?

A
  1. A disturbance in attention (reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to environment)
  2. An acute change that develops over a short period of time (hours - days) and tends to fluctuate
  3. An additional disturbance in cognition (memory deficit, disorientation, language, perception, visuospatial ability)
  4. Changes NOT accounted for by another pre-existing, evolving or established neurocognitive disorder
  5. Evidence from history, physical exam or lab findings of an organic cause (medical condition, substance intoxication or withdrawal, medication side effect)
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3
Q

What are the 2 main subtypes of delirium?

A
  1. Hyperactive
  2. Hypoactive

N.B. Patients can fluctuate between these -‘mixed’

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4
Q

Describe some clinical features of hyperactive delirium

A
  • Increased motor activity
  • Agitation
  • Hallucinations
  • Inappropriate behaviour
  • Aggression
  • Delusions
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5
Q

What subtype is often the ‘typical’ delirium presentation?

A

Hyperactive

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6
Q

Describe some clinical features of hypoactive delirium

A
  • Reduced motor activity and lethargy
  • Excessive sleeping
  • May appear withdrawn
  • Loss of appetite
  • Not moving as much
  • Not talking as much
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7
Q

What can hypoactive delirium sometimes be confused with?

A

Depression

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8
Q

What is the prevalence of delirium in all elderly inpatients?

A

20-30%

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9
Q

What is the prevalence of delirium in all patients with dementia??

A

66%

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10
Q

How can delirium affect patient outcomes in hospital?

A

◦Longer lengths of stay

◦More hospital associated complications, such as pressure sores and falls

◦More likely to be admitted to long term care

◦More likely to have underlying dementia (diagnosed or undiagnosed)

◦More likely to die

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11
Q

Is delirium reversible?

A

Yes

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12
Q

Give some risk factors for delirium

A
  • Age >65
  • Serious illness
  • Hip fracture
  • Known dementia
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13
Q

What question can be used to initially screen for delirium?

A

Is this person more confused than normal?

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14
Q

If the patient does appear to be more confused than normal, what are 2 different screening tools that can be used when screening for cognition?

A
  1. 4AT
  2. AMTS
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15
Q

What is involved in the AMTS?

A

Abbreviated Mental Test Score

This is composed of 10 questions:

  1. Age
  2. Time (to the nearest hour)
  3. Recall (e.g. ask the patient to remember the address and get hem to repeat it back to you later)
  4. Current year
  5. Current location
  6. Recognise 2 people (e.g. relatives, carers, likely profession of doctor/nurse)
  7. DOB
  8. Year of 1st / 2nd word war
  9. Name of current monarch / prime minister
  10. Count backwards from 20 to 1
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16
Q

What score on the AMTS implies cognitive impairment?

A

< or equal to 8

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17
Q

Give some limitations of the AMTS

A
  • Patients with a reduced GCS
  • Language barrier
  • Younger generation (e.g. WW1 dates)
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18
Q

What is involved in the 4AT?

A
  1. Alertness
  2. AMT4 cognition test → age, DOB, location, current year
  3. Attention → ask patient to list months in reverse order
  4. Acute change or fluctuating course
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19
Q

What is the first step in the management of delirium?

A

Find and Treat Reversible Causes

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20
Q

Reversible causes of delirium → PINCH ME

A

Pain

Infection

Nutrition

Catheters and constipation

Hypoxia and hydration

Medications and metabolic

Environment

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21
Q

How can ‘pain’ as a cause of delirium be managed?

A
  • Consider causes of pain
  • Look for non-verbal signs of pain
  • Consider prescribing analgesics e.g. paracetamol
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22
Q

Which infection most commonly causes delirium in the elderly?

A

UTI

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23
Q

What examination finding may indicate a UTI in a patient with delirium?

A

Suprapubic tenderness

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24
Q

What investigations should be considered if an infection is thought to be the cause of delirium?

A

Blood tests - FBC (raised WCC), CRP (raised)

MSU (raised nitrites or leukocyte esterase)

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25
Q

In which patients would a head injury be considered to be the cause of delirium?

A

Patients on anticoagulation with a history of head injury regardless of neurology OR

If any focal neurology

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26
Q

Which investigation would be done in patients with a suspected head injury presenting with delirium?

A

CT head

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27
Q

Define carphology

A

The motion of delirious or senile patients, especially motions of searching for and grasping at imaginary objects, plucking at bedclothes. An aimless semiconscious plucking at bedclothes observed in conditions of exhaustion or stupor or in high fevers.

28
Q

Which 2 factors alone can cause delirium without any deeper organic cause? (N.B. this should only be considered as a diagnosis of exclusion)

A

Change of environment + sensory impairment (e.g. vision, hearing)

29
Q

Poor nutrition can precipitate delirium, but more often is a consequence of the increased confusion. What simple measures can encourage oral intake on the ward?

A
  • Well fitting dentures
  • Treating oral thrush
  • Appetising meals/finger foods
  • Red trays and dementia crockery and cutlery
30
Q

What is the purpose of a red tray on the wards?

A

A red tray is used on the wards, in hospital to help staff identify which patients need extra attention when eating, or need foods that have a modified texture (such as mashed or pureed foods).

The aim of using a red tray is to monitor and help these patients when eating so their dietary needs are met.

31
Q

Which clinical sign may be present if constipation is thought to be the cause of delirium?

A

Distension

Palpation, especially in thin patients, may reveal hard, palpable stool in the colon.

32
Q

Which investigations could be done constipation is thought to be the cause of delirium?

A

Abdo exam

PR exam

33
Q

Management for constipation as the cause of delirium?

A

Laxatives

Stool chart

Ensure regular toileting regime

34
Q

Which clinical sign may be present if urinary retention is thought to be the cause of delirium?

A

Palpable bladder during abdo exam

35
Q

Which investigations could be done urinary retention is thought to be the cause of delirium?

A

Bladder scan

36
Q

Which investigation could be done if hypoxia is thought to be the cause of delirium?

A

Check O2 sats

37
Q

Dehydration can precipitate or be a consequence of delirium. What investigation can be done to assess dehydration?

A

U&Es

38
Q

Management for dehydration as the cause of delirium?

A
  • Beside hydration assessment
  • Offer regular drinks
  • Ensure drinks are within reach
  • Consider s/c or IV fluids if not drinking adequately
39
Q

Give some ways in which drugs can lead to delirium

A
  • Opioids
  • Withdrawal
  • Illicit drugs
  • Intoxication
  • Hypoglycaemia
40
Q

Which investigation could be done if drugs are thought to be the cause of delirium?

A

Review medications and stop unnecessary drugs

41
Q

Give a list of investigations to do in any patient presenting with delirium

A
  • Bloods - FBC, U&Es, LFTs, TFTs, CRP
  • Extra bloods - Calcium, B12, folate, TFTs
  • Capillary blood glucose
  • CT head scan (if head injury suspected)
  • Urinalysis
  • Med chart
  • O2 sats
  • Abdo exam
  • Bladder scan
  • PR exam
42
Q

Non-pharmalogical management of delirium should always be first line.

When should medication only be considered?

A

If the patient is a risk to themselves or others –> start low go slow

43
Q

What is the 1st line pharmacological treatment of delirium?

A

Low dose haloperidol

If benzos are to be used –> lorazepam is 1st line due to rapid onset and short half-life

44
Q

What class of medication is haloperidol?

A

Typical antipsychotic

45
Q

Give some infections that can cause delirium

A
  • UTIs
  • Pneumonia
  • Cellulitis
  • Ulcers
46
Q

Give some nutritional deficiencies that can cause delirium

A

B12

Folate

Hypoglcyaemia

47
Q

What hormone electrolyte imbalances can lead to delirium?

A

Calcium –> hypercalcaemia
Sodium –> hyponatraemia
Glucose –> hyper/hypoglycaemia
Thyroid –> hypothyroidism

48
Q

What kidney issues can lead to delirium?

A

AKI
CKD

49
Q

What brain pathologies can lead to delirium?

A

REMEMBER TO ASK ABOUT FALLS

  • Stroke
  • Subdural
  • Tumour
50
Q

Which conditions can lead to hypoxia or hypercapnia that can then lead to delirium?

A
  • Infection
  • Heart failure
  • Lung disease e.g. COPD
51
Q

Which drugs are known to precipitate delirium (so should be avoided in these patients)?

A

Opiates, benzos

52
Q

What are the 3 subtypes of delirium?

A

1) hyperactive

2) hypoactive

3) mixed

53
Q

What is hyperactive delirium marked by?

A

Increased psychomotor activity, restlessness, agitation & hallucinations.

54
Q

What is hypoactive delirium marked by?

A

Lethargy, reduced responsiveness, withdrawal.

55
Q

What is mixed delirium?

A

Combines featres of both hyperactive and hypoactive.

56
Q

Management of delirium?

A

1) correct any precipitating factors e.g. constipation

2) non-pharmalogical strategies:
- providing an environment with good lighting
- maintaining a regular sleep-wake cycle
- regular orientation and reassurance
- ensuring the patient’s glasses and hearing aids are used if needed

3) pharmalogical strategies:
- haloperidol 1st line
- lorazepam (if haloperidol contraindicated eg. Parkinson’s)

57
Q

When are pharmacological interventions indicated in delirium?

A

For patients who are extremely agitated and potentially a danger to themselves or others.

58
Q

1st line pharmacological management of delirium?

A

Haloperidol

59
Q

Pharmacological management of delirium in Parkinson’s?

A

Lorazepam

60
Q

What is the established screening tool for delirium in patients with established acute confusion (i.e. after a +ve single question in delirium)?

A

AMT4

61
Q

What makes up the DSM V criteria for delirium? (5)

A

1) Disturbance in ATTENTION (reduced ability to direct, focus, sustain and shift attention) and AWARENESS (reduced orientation to environment)

2) An acute change and tends to fluctuate

3) An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability or perception)

4) The disturbances are not better explained by another neurocognitive disorder

5) Evidence that it is caused by a medical condition, intoxication or side effect

62
Q

Why do we check for epithelial cells in urine microscopy & culture?

A

Epithelial cells indicate the urine sample container has touched the skin during the collection process (contamination).

63
Q

General mx of delirium?

A

1) Recognition is key to allowing prompt management

2) Conservative measures:
- reassurance
- close nursing supervision
- removal of unnecessary stimuli to promote rest/sleep
- risk reduction e.g. falls

3) Family involvement is key - reassuring to patient

4) Restriction (either medical or physical) is last resort

64
Q

What is 1st line pharmacological mx of delirium?

A

1) Oral lorazepam (IM only when absolutely necessary)

2) If already taking benzos or at risk of respiratory depression –> use oral haloperidol

65
Q

Above what age is a risk factor for delirium?

A

> 65

66
Q
A

Yr 4 - Psychiatry (17 decks)

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