Delirium Flashcards
Medications that may contribute to delirium
- Diphenhydramine - anticholinergic sfx
- Dexamethasone - agitation, sleep disturbance, risk for psychosis
- Clonazepam - sedation, cognitive impairment
- Carbamazepine - GABA agonist, confusion, drowsiness
What are 13 risk factors for post surgical delirium?
- Underlying cognitive impairment
- History of delirium
- General anesthetic/duration of surgery
- Older age
- Underweight BMI<18.5
- Male sex
- Low education
- Institutionalized
- Polypharmacy
- Smoker
- More comorbidities
- Higher ASA status
- Higher pre op CRP
What are the four conclusions from the Cochrane review for treatment of delirium in non ICU patients with antipsychotics?
- No evidence to determine if they reduce duration
- No evidence that they resolved symptoms
- Do not reduce delirium severity
- Do not alter mortality or AE rates
- No difference between typical and atypical in terms of EPS
What are 11 predisposing risk factors for delirium that are not related to the patient’s reason for admission to hospital?
- Older age
- Low education level
- Hx of cognitive impairment
- Hx of delirium
- Multiple comorbidities
- Frailty
- Vision/hearing impairment
- Depression
- Alcohol abuse
- Illicit drug, opioid or benzodiazepines use
- Poor nutrition
Name 4 reasons why hypoactive delirium is often underreported and under treated?
- Not as easily identified as no behavioural issues, perceived as cooperative
- Lack of training in using validated screening tools
- HCPs overlook sx of delirium in patients with dementia
- Over reliance on disorientation for detection, poor Sn and Sp
What are biomarkers for delirium?
- IL 6
- IL 8
- CRP
- Neurodegeneration
- Synaptic function on EEG and MRI
What are two indications for prescribing antipsychotics in patient with delirium?
- Patient at risk of harming themselves
- Patient at risk of harming others
- Distressing symptoms like hallucinations
What is the role of dexmedetomidine in delirium prevention?
Recommended for prevention of delirium in post ICU and post op settings
Reduce incidence of delirium in multiple surgical populations: cardiac, non cardiac, LE orthopaedic, joint replacement, liver transplant
SFx: bradycardia, hypotension, rare HTN
What are 5 features of delirium that are associated with increased mortality?
- Altered arousal
- Inattention
- Disorientation
- Memory deficits
- Disorganized thinking
What are 10 recommendations for the prevention of delirium?
- Address disorientation - signage, clock, calendar, talk to them
- Address dehydration
- Address constipation
- Address hypoxia
- Address infection
- Address immobility
- Address pain
- Medication review
- Address sensory impairment
- Promote good sleep
What are the CAM criteria and how to use it?
- Acute onset and fluctuating course
AND - Inattention
Plus one of: - Altered LOC
- Disorganized thinking
Based on observations made during brief but formal cognitive testing
If during routine clinical care missed in 80% of observations and 70% of cases
What is the Sn and Sp of CAM?
Sn 94-100%
Sp 90-95%
Post discharge from hospital what are 5 risk factors for persistent delirium?
- Dementia
- Functional impairment
- High comorbidity
- Vision impairment
- Use of physical restraints
What is the recommended first line intervention for hyperactive delirium?
Short term Haldol
Start at lowest dose 0.25 - 0.5 mg PO ID/BID
Max 2.5 mg in first 24 hours
Need to monitor QTc
Can also use atypical antipsychotic
What are side effects of Haldol?
- Inc risk of death
- EPS
- Sedation
- HOTN
- QT prolongation
- PE
- Constipation
- Tremor
What are outcomes of persistent delirium after discharge?
- Inc mortality
- Inc nursing home placement
- Decreased function
- Decreased cognition
What are indications for neuroimaging with delirium?
- Acute focal neurologic findings
- Hx of recent fall/head trauma
- Fever with suspicion for encephalitis
- Dec LOC with no identified cause
What is the strongest independent risk factor for delirium in older patients with COVID-19?
Previous cognitive impairment
In the CAM-ICU, how are attention and LOC recommended to be assessed?
Attention - squeeze on letter A in string of 10 letters
LOC - validated sedation scale like the RASS
Describe 3 potential challenges to delirium screening for critically ill older adults specifically during COVID-19?
- PPE makes communication harder
- PPE less trusting and willing to participate in screening
- Family not at bedside
- Staffing shortage
Based on PADIS guidelines what are 2 validated delirium screening tools to use in ICU?
CAM-ICU
ICDSC (Intensive care delirium screening checklist)
What are risk factors for delirium specific to ICU setting as per PADIS?
- Older age
- Dementia
- Benzo use
- Blood transfusions
- Prior coma
- Higher ASA scores
- Higher APACHE scores
- Pre-ICU emergency surgery or trauma
Name 3 neurotransmitters that have possible roles in the pathophysiology of delirium?
Ach
Dopamine
5-HT
NE
Glutamate
GABA
What did the JAGS 2016 systematic review on oral antipsychotics show?
No effect on delirium incidence
Not associated with change in duration, severity, hospital or ICU LOS
No association with mortality
Not supported for prevention or treatment
NEJM 2022 Haldol in ICU for patients with delirium
Haldol vs. placebo
No significant difference for two outcomes:
Number of days alive and out of hospital at 90 days
Mortality may have been lower in Haldol group
What are 5 intraoperative surgical factors that have potential to precipitate delirium?
- Duration of surgery
- Type of anesthesia
- Depth of anesthesia
- Intraoperative blood loss
- Intraoperative hemodynamics/hypotension
- Neurologic injury or covert stroke
