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.
The pathophysiology of delirium is poorly understood.
Describe the current schoool of thought behind delirium [1]
Problem with global cortical dysfunction of which one of the dominant mechanisms is abnormal neurotransmitters in the brain such as reduced levels or acetylcholine or increased levels of dopamine.
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 Patients may appear quiet, lethargic, withdrawn and have reduced concentration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
* attentional deficits
* impairment of consciousness: hyperalertness to stupor; may fluctuate
* fluctuation of symptoms: worse at night, periods of normality
* abnormal perception (e.g. illusions and hallucinations) - visual hallucination is almost always associated with delirium
* Emotional disturbance: agitation, fear
* Abnormal perceptions: visual or auditory hallucinations; paranoid 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)
Describe the Confusion Assessment Method (CAM) used to screen delirium [4]
Overview: brief assessment tool based on four features
* (1) Acute & fluctuating course
* (2) Inattention
* (3) Disorganised thinking
* (4) Altered level of consciousness
Time: < 5 minutes
Setting: hospital or community
Diagnosis for delirium: presence of 1 AND 2 plus either 3 OR 4
Describe the 4A’s test for screening delirium [4]
Overview: a screening tool for delirium that involves four screening questions
* (1) Alertness
* (2) Four AMT questions: age, date of birth, place, current year
* (3) Attention: list months in reverse order starting with December
* (4) Acute change or fluctuating course
Time: < 5 minutes
Setting: hospital
Score: 1-3 (possible dementia), 4-12 (possible dementia/delirium)
Describe the Abbreviated mental test (AMT) used for screening delirium [3]
Overview: a ten item scoring tool predominantly used in hospital settings (e.g. hospital ward).
Time: < 5 minutes
Setting: hospital and General practice
Cut-off for delirium: 6-7/10
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
Patients with delirium usually lack capacity to make decisions about their care. Therefore, we have to treat them in their best interests using the [] Act
Patients with delirium usually lack capacity to make decisions about their care. Therefore, we have to treat them in their best interests using the Mental Capacity Act (MCA).
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
Which pain scale can you use to assess pain if they can’t communicate? [1]
Abbey Pain Scale
