Delirium Flashcards
Describe what is meant by delirium [1]
Delirium refers to an acute confusional state that causes disturbed consciousness, attention, cognition & perception.
Delirium is typically acute onset and fluctuates throughout the course of the day.
Describe the three different types of delirium [3]
The clinical features of delirium allow it to be divided into three subtypes:
Hyperactive delirium:
- characterised by inappropriate behaviour, agitation or hallucinations. Wandering and restlessness are common
- changes in sleep cycle
Hypoactive delirium:
- characterised by reduced activity. Patients may appear quiet, lethargic, withdrawn and have reduced concentration
- Worse outcomes in hypoactive subtypes
- changes in sleep cycle
Mixed delirium:
- characterised by the presence of both hypoactive and hyperactive features
Which factors would favour that a person is suffering from delirium over dementia? [5]
Aka describe the clinical features of delirium
Factors favouring delirium over dementia
* acute onset
* impairment of consciousness
* fluctuation of symptoms: worse at night, periods of normality
* abnormal perception (e.g. illusions and hallucinations) - visual hallucination is almost always associated with delirium
* agitation, fear
* delusions
* Sleep-Wake Cycle Disturbances: patients often experience insomnia during the night and excessive sleepiness during the day.
* Anxiety, irritability, apathy or depression are common emotional manifestations of delirium.
* Deficits in memory, particularly short-term memory, orientation and language are common
Dementia is more likely if:
- slowly progressive with limited fluctuation
- Attention is usually in tact and very early memories may be preserved
NB: can be hyper/hypo/mixed changes
ASK what they’re experiencing / feeling
Describe the diagnostic criteria used to diagnose delirium
DSM-5 criteria:
- Disturbance in awareness (e.g. disorientated to time, place, person) and attention (e.g. unable to subtract serial 7’s)
- Acute onset (hours to days), acute change from baseline, and fluctuant
- Disturbance in cognition (e.g. memory loss, misperception)
- Not better explained by a pre-existing, established, or evolving neurocognitive disorder and absence of severely reduced GCS
- Evidence of an organic cause (i.e. medical condition, medication, intoxication)
A number of cognitive assessment tools can be used at the bedside to enable a diagnosis of delirium.
Three commonly used criteria include: [3]
- Confusion Assessment Method (CAM)
- The 4A’s test (4AT)
- Abbreviated mental test (AMT)
What does the PINCHME pneumonic stand for (for ID causes of delirium?)
Pain
Infection
Nutrition
Constipation
Hydration
Medications
Envirionment
Despite simple deescalation methods, patients with delirium may still pose significant psychological or physical harm to themselves and there may be risk of harm to others within the environment (e.g. patients, staff).
In these situations, the use of short-term pharmacological measures may be needed that is often referred to as rapid tranquillisation.
Name two drugs that could be used? [2]
Benzodiazepines (e.g. lorazepam)
Anti-psychotics (e.g. haloperidol, olanzepine)
The oral route should always be used in preference, but if not possible, then the intramuscular route is used
A person lacks capacity if they cannot do one or more of the following [4]
A person lacks capacity if they cannot do one or more of the following:
Understand the information relevant to the decision
Retain the information long enough to be able to make the decision
Use or weigh up information available to make the decision
Communicate their decision
Which drugs are known to causes delirium
Anticholinergics, sedatives, opioids and polypharmacy in general.
How would you differentiate delirium to pyschosis? [3]
Pyschosis:
- hallucinations are typically auditory
- Do NOT show altered level of consciousness
- Demonstrate loosening of associations or tangentiality (whereas delirium exhibit an impaired ability to maintain a coherent stream of thought due to attention deficits)
NB: pyschosis is a more specific mental health illness
How would you differentiate delirium to depression? [3]
The onset of depression is generally more gradual than that of delirium.
Depressive symptoms including low mood, loss of interest or pleasure in activities (anhedonia), feelings of worthlessness or excessive guilt are not typically observed in delirium unless it coexists with depression.
Depression occurs for most of every day - 2 weeks
Patients with depression often complain about concentration difficulties but they do not exhibit the marked attention deficits characteristic of delirium
Which age group is hypoactive delirium more common in? [1]
Hypoactive delirium
- is more common in older adults and is often under-recognised due to its less dramatic presentation compared to hyperactive delirium.
Which screening tool should you use for ? delirium? [1]
4-AT
What is the underlying pathophysiological change in neurotransmitters seen in delirium? [1]
deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release;
Which pain scale can you use to assess pain if they can’t communicate? [1]
Abbey Pain Scale
