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A. MLA Map Medicine of Older Adults > Delirium > Flashcards

Delirium Flashcards

1
Q

What is delirium?

1 - disturbance in attention
2 - develops over a short period and tends to fluctuate in severity
3 - disturbance in cognition
4 - direct consequence of another medical condition
5 - cannot be explained by another neurological disorder
6 - all of the above

A

6 - all of the above

  • according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
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2
Q

Delirium can occur at all ages in men and women. What % of patients on a general ward (medical or surgical) are likely to experience delirium?

1 - 3%
2 - 13%
3 - 33%
4 - 63%

A

3 - 33%

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3
Q

Delirium can occur at all ages in men and women. What % of patients in ICU are likely to experience delirium?

1 - 3%
2 - 13%
3 - 33%
4 - 70%

A

4 - 70%

  • association between physical illness and risk of delirium
  • more common in ICU / HDU admission, Post emergency laparotomy, Hip fracture and Stroke, >65, ALL OF THESE PATIENTS SHOULD BE SCREENED FOR DELIRIUM
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4
Q

Almost any illness can lead to delirium, but is there an association between illness severity and delirium?

A
  • yes
  • more severe illness is more likely to cause delirium
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5
Q

Which of the following is NOT a risk factor for delirium?

1 - Age
2 - Gender
3 - Pre-existing cognitive impairment
4 - Frailty

A

2 - Gender

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6
Q

Although delirium can occur in anyone, which groups of patients have a greater risk of developing delirium when compared to the general public?

1 - dementia patients
2 - neurological conditions
3 - mood disorder (depression, bipolar etc..)
4 - anxiety disorder
5 - all of the above

A

5 - all of the above

  • dementia patients account for up to 50% of delirium cases
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7
Q

Which of the following is a typical differential for delirium?

1 - dementia
2 - depression
3 - non-organic psychosis
4 - Encephalitis
5 - Non-convulsive status epilepticus
6 - Post-ictal (following seizure) phase
7 - Psychiatric diagnoses
8 - all of the above

A

8 - all of the above

  • organic = specific illness with physical, biochemical or imagery to confirm diagnosis
  • inorganic = unknown cause and unclear of the causer
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8
Q

When trying to diagnose a patient with delirium, does the patient or a collateral more likely go provide more useful information?

A
  • collateral
  • family, carer etc..
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9
Q

According to NICE guidelines, which assessment tool should be used in a patient with suspected delirium?

1 - Abbreviated mental test score (AMTS)
2 - Mini-mental state examination (MMSE)
3 - V Montreal Cognitive Assessment (MoCA)
4 - 4AT assessment

A

4 - 4AT assessment
- score >4 indicates delirium

  • Abbreviated mental test score (AMTS) may also be useful
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10
Q

All of the following are common presentations of delirium, EXCEPT which one?

1 - impaired awareness, attention and concentration
2 - disorientated
3 - palsy
4 - memory present, but lack of awareness
5 - hallucinations, especially visual
6 - delusions
7 - mood

A

3 - palsy

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11
Q

Which of the following is important when trying to diagnose a patient with delirium?

1 - full history
2 - physical examination
3 - medication history
4 - substance misuse history
5 - all of the above

A

5 - all of the above

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12
Q

Which of the following are important physical investigations when trying to diagnose a patient with delirium?

1 - biochem and haematology
2 - blood and urine culture
3 - ABG
4 - ECG
5 - chest X-ray
6 - abbreviated mental test score (AMTS)
7 - mini mental state examination (MMSE)
8 - all of the above

A

8 - all of the above

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13
Q

In patients with delirium, do they always experience a suppression of their normal cognitive state?

A
  • no
  • can be hyper, hypo or mixed
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14
Q

When talking about hallucinations and delusions, which one goes with the following definitions?

1 - false belief
2 - sensory perception

A

1 - false belief = delusions

2 - sensory perception = hallucinations

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15
Q

Which of the following is NOT associated with hyperactive delirium?

1 - Hallucinations
2 - Confusion
3 - Delusions
4 - Anger
5 - Irritability

A

2 - Confusion

  • least common, but are often the most common to present early
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16
Q

Which of the following is NOT associated with hypoactive delirium?

1 - somnolence (drowsiness and need to sleep)
2 - withdrawn
3 - fatigued
4 - angry

A

4 - angry

  • more common than hyperactive, but less likely to be detected
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17
Q

Which of the 3 is the most common subtype of delirium?

1 - hyperactive
2 - hypoactive
3 - mixed

A

3 - mixed

  • periods of hypo-activity and hyperactivity
  • fluctuating over hours and days
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18
Q

Is hypoactive or hyperactive delirium associated with worse outcomes?

A
  • hypoactive delirium
  • reduced oral intake
  • immobilisation
  • pressures sores
  • hospital acquired infection
  • longer length of stay
  • institutionalisation
  • increased mortality
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19
Q

What is often the best way to identify if a patient has delirium?

1 - acute onset
2 - duration of symptoms
3 - severity of symptoms
4 - changes in cognition

A

1 - acute onset

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20
Q

Which of the following is NOT a differential for when a patient presents with hypoactive delirium?

1 - Severe depression
2 - Post-ictal phase
3 - Non-convulsive status
4 - Encephalitis
5 - Psychosis

A

5 - Psychosis

  • Encephalitis is inflammation of the brain causes confusion, drowsiness, weakness
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21
Q

Which 2 of the following are differentials for when a patient presents with hyperactive delirium?

1 - behavioural and psychological symptoms of dementia
2 - epilepticus (seizure >5 mins)
3 - psychosis
4 - severe depression

A

1 - behavioural and psychological symptoms of dementia

3 - psychosis

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22
Q

When we compare dementia and delirium, which has rapid onset and which has a gradual development over time?

A
  • rapid onset = delirium
  • gradual decline = dementia
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23
Q

When we compare dementia and delirium, which can cause a change in alertness?

A
  • delirium = alertness can increase or decrease
  • dementia = remains normal
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24
Q

When we compare dementia and delirium, which has changes in attention?

A
  • delirium = impaired attention
  • dementia = normally preserved
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25
Q

When we compare dementia and delirium, which is more likely to have hallucinations?

A
  • delirium = common
  • dementia = rare (except in Dementia with Lewy bodies)
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26
Q

When we compare delirium and dementia, which has fluctuations in cognition and awareness?

A
  • delirium = fluctuations during day
  • dementia = gradual change over time
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27
Q

When we compare delirium and dementia, which has changes in mood?

A
  • delirium = mood often fluctuates
  • dementia = mood may be low, doesn’t usually fluctuate
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28
Q

What % of patients with a hip fracture will experience delirium?

1 - 1%
2 - 10%
3 - 20%
4 - 50%

A

4 - 50%

  • 4-12% in the community
  • 4-38% in nursing homes)
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29
Q

To help identify the cause of delirium, we can use the mnemonic PINCH ME. What does the P stand for?

1 - pain
2 - pressure (BP)
3 - pleural effusion
4 - percussion of chest is dull

A

1 - pain

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30
Q

To help identify the cause of delirium, we can use the mnemonic PINCH ME. What does the I stand for?

1 - insomnia
2 - infection
3 - idiopathic

A

2 - infection

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31
Q

To help identify the cause of delirium, we can use the mnemonic PINCH ME. What does the N stand for?

1 - NAFLD
2 - narcolepsy
3 - nutrition
4 - nystagmus

A

3 - nutrition

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32
Q

To help identify the cause of delirium, we can use the mnemonic PINCH ME. What does the C stand for?

1 - colon obstruction
2 - cancer
3 - cataracts
4 - constipation

A

4 - constipation

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33
Q

To help identify the cause of delirium, we can use the mnemonic PINCH ME. What does the H stand for?

1 - hydration
2 - heart disease
3 - hearing loss
4 - haemorrhage

A

1 - hydration

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34
Q

To help identify the cause of delirium, we can use the mnemonic PINCH ME. What does the M stand for?

1 - malaria
2 - muscle loss
3 - medication
4 - measles

A

3 - medication

35
Q

To help identify the cause of delirium, we can use the mnemonic PINCH ME. What does the E stand for?

1 - epilepsy.
2 - erectile dysfunction
3 - encephalitis
4 - environment

A

4 - environment

36
Q

Causes of delirium can be categorised into predisposing and precipitating factors. What are predisposing factors?

1 - conditions present prior to delirium
2 - genetic risk factors
3 - polypharmacy patients
4 - identified factors that are treatable

A

1 - conditions present prior to delirium

  • can help identify which patients are at risk of delirium
37
Q

Causes of delirium can be categorised into predisposing and precipitating factors. What are precipitating factors?

1 - conditions present prior to delirium
2 - genetic risk factors
3 - polypharmacy patients
4 - factors identified that are treatable

A

4 - factors identified that are treatable

  • if we can treat them then we can stop delirium
38
Q

Are all causes of delirium caused by one thing?

A
  • no
  • generally multifactorial
39
Q

Which of the following are looked at as the big 3 predisposing factors that can cause delirium?

1 - Older age
2 - Dementia and cognitive impairment
3 - Gender (male)
4 - Frailty
5 - Sensory impairments
6 - Polypharmacy

A

1 - Older age
2 - Dementia and cognitive impairment
4 - Frailty

  • all others are also factors though
40
Q

The following are all precipitating factors causing delirium:

  • Infection
  • Metabolic changes
  • Pain
  • Constipation
  • Urinary retention
  • Dehydration
  • Surgery and anaesthesia
  • Medications – initiation and abrupt cessation
  • Alcohol withdrawal
  • Head injuries and fractures
A
41
Q

Which of the following medications has been associated with delirium?

1 - Steroids
2 - Benzodiazepines
3 - Tricyclic antidepressants
4 - Antihistamines – chlorpheniramine
5 - Anticholinergics – solifenacin
6 - Opiates
7 - Digoxin
8 - all of the above

A

8 - all of the above

42
Q

Withdrawal from which of the following has NOT been associated with delirium?

1 - benzodiazepines
2 - anxiolytics (anxiety medications)
3 - anti-depressants
4 - alcohol

A

3 - anti-depressants

43
Q

What is delirium tremens?

1 - syndrome cause by drug withdrawal
2 - syndrome caused by alcohol withdrawal
3 - syndrome caused by allergic reaction to drugs

A

2 - syndrome caused by alcohol withdrawal

  • tremens = most severe form of ethanol withdrawal
  • acute confusion occurs 3-10 days following cessation
44
Q

Delirium tremens is a syndrome caused by alcohol withdrawal. Which of the following does NOT generally occur?

1 - acute confusion
2 - tactile hallucinations / formication
3 - insomnia
4 - physical manifestations of alcohol withdrawal
5 - seizures and can be life threatening

A

3 - insomnia

45
Q

In a patient with delirium tremens, what medication can be used to help alleviate their symptoms?

1 - Antipsychotics
2 - Benzodiazepines
3 - Analgesia
4 - Acetylcholinesterase inhibitors

A

2 - Benzodiazepines

  • Diazepam, Lorazepam*, Chlordiazepoxide (MOST COMMON)
  • all bind with gamma subunit on GABA a receptor, causing increased Cl- into cell
46
Q

We know that the pathophysiology of delirium is likely to be multifactorial. Which of the following is NOT a common cause linked with delirium due to a direct brain insult?

1 - Hypoxia
2 - Hypoglycaemia
3 - Metabolic abnormalities
4 - Haemorrhage
5 - Stroke
6 - Drugs affecting the CNS

A

4 - Haemorrhage

47
Q

We know that the pathophysiology of delirium is likely to be multifactorial. Which of the following is NOT a common cause linked with delirium due to a dysfunctional stress response?

1 - Peripheral stress event – infection/injury
2 - parasympathetic nervous system
3 - Sympathetic nervous system
4 - Hypothalamic-pituitary-adrenal axis
5 - Inflammatory pathways

A

2 - parasympathetic nervous system

  • more associated with rest and digest
48
Q

Neuronal ageing increases the brains susceptibility to delirium. The following have been linked with delirium:

1 - brain network connectivity impaired with neuronal loss
2 - degeneration cholinergic and noradrenergic neuronal populations
3 - neuroinflammation:
Microglia & astrocytes - exaggerated pro-inflammatory responses to secondary inflammatory stimuli
4 - Glial cell alterations:
Astrocytes metabolically impaired
5 - Vascular changes :
Impaired brain perfusion and vascular reactivity
6 - Blood brain barrier:
Disruption of transport plasma proteins into brain and increased permeability blood brain barrier to toxins

A
49
Q

Neuroinflammatory hypothesis identified possible causes of delirium. The following have been linked:

1 - infection, trauma, surgery
2 - cytokine release – Interleukin-1β, TNF
3 - Microbial products – Lipopolysaccharide
4 - Activate the brain:
Increased permeability of the Blood Brain Barrier
5 - Inflammatory process
6 - Effects neuronal energy production and promotes cell dysfunction, injury and death
7 - Coagulation promoted – impairs cerebral autoregulation, can => thrombosis & ischaemia
8 - Prior brain vulnerability explains heterogenous presentations

A
50
Q

Cerebral metabolic insufficiency hypothesis is when insufficient glucose reaches the brain. It can be due to:

1 - Oxygen:
- Hypoxaemia (direct or indirect) is associated with reduced Acetycholine production
- Oxidative stress can trigger dopamine release which may cause perceptual problems in delirium

2 - Glucose:
- Hypoglycaemia causes delirium
Impaired glucose uptake with insulin insensitivity in seen in - trauma, surgery, sepsis

A
  • low oxygen and glucose cause delirium
51
Q

Glucocorticoids: Neuroendocrine hypothesis is related to the amount of cortisol that reaches the brain. Linked with:

1 - activation of HPA axis with no efficient negative feedback causing hippocampal dysfunction, neuronal dysfunction and neuronal cell death

2 - exogenous steroids which can trigger delirium

A
52
Q

Circadian rhythm dysregulation hypothesis, which is when there are disturbances between melatonin and cortisol. The following occurs:

1 - Melatonin – from pineal gland controls circadian rhythms. Disturbances in sleep pattern can precipitate delirium

2 - Acute and chronic sleep deprivation are stressors that can increase inflammation, cortisol, sympathetic activity

A

3 - Potential role in melatonin in delirium prevention

53
Q

The neurotransmitter (NT) hypothesis essentially indicates that there is alterations in and functions in NT in delirium. The following have all been implicated in this hypothesis:

1 - reduced availability of acetylcholine
2 - excess release of dopamine, noradrenaline and glutamate
3 - alterations (either up or down, situation dependent) of histamine, serotonin, GABA
4 - delirium is considered a hypocholinergic-hyperdopaminergic state (influence other NT systems)

A
54
Q

The neurotransmitter (NT) hypothesis essentially indicates that there is alterations in and functions in NT in delirium. The following have all been associated with reduction in Acetylcholine (ACh):

1 - ACh receptor antagonists cause EEG slowing
2 - Increased anticholinergic burden increases delirium risk
3 - Disruption in cholinergic function causes delirium but not always present
4 - No evidence for acetylcholinesterase inhibitors in delirium

A
55
Q

The neurotransmitter (NT) hypothesis essentially indicates that there is alterations in and functions in NT in delirium. The following have been linked with histamine:

1 - H1 and H2 receptor antagonists can cause sedation and delirium

A
56
Q

The neurotransmitter (NT) hypothesis essentially indicates that there is alterations in and functions in NT in delirium. The following have been linked with increased dopamine:

1 - hyperdopaminergic theory in delirium - but inconsistent response to anti-psychotics
2 - psychomotor state may be affected during delirium (hyper-/hypo-active)

A
57
Q

The neurotransmitter (NT) hypothesis essentially indicates that there is alterations in and functions in NT in delirium. Noradrenaline (NA) has been studied and has shown the following”

1 - Low NA – reduced wakefulness (hypoactive delirium)
2 - High NA – poor attention, emotional responses – fear/threat (hyperactive delirium)
3 - Sympathetic nervous system activated by inflammation, trauma, sepsis, psychological stress, pain:
4 - ↑NA associated with post op delirium in older adults having major surgery
5 - Excessive NA drive seen in alcohol withdrawal => high BP, agitation and tremor

A
58
Q

Opiods are associated with delirium. What is the link?

1 - increased dopamine and ACh
2 - decreased dopamine and ACh
3 - increased dopamine and decreased ACh
4 - decreased dopamine and increased ACh

A

3 - increased dopamine and decreased ACh

59
Q

Antipsychotics are associated with delirium. What is the link?

1 - increased dopamine
2 - decreased dopamine
3 - increased noradrenaline
4 - decreased noradrenaline

A

2 - decreased dopamine

  • essentially cause hypoactive delirium
60
Q

Benzodiazepine are associated with delirium. What is the suspected mechanism?

1 - decrease GABA
2 - increase noradrenaline
3 - increase GABA
4 - increase dopamine

A

3 - increase GABA

  • essentially cause hypoactive delirium
61
Q

Anti-histamine are associated with delirium. What is the suspected mechanism?

1 - decrease GABA
2 - increase GABA
3 - decrease histamine and anticholinergic
4 - increased histamine and anticholinergic

A

3 - decrease histamine and anticholinergic

62
Q

Cardiac glycoside are associated with delirium. What is the suspected mechanism?

1 - decrease GABA
2 - increase GABA
3 - decreased depolarisation and anticholinergic
4 - increased histamine and anticholinergic

A

3 - decreased depolarisation and anticholinergic

  • inhibits membrane Na+K+ATPase affecting neuronal function
63
Q

Steroids are associated with delirium. What is the suspected mechanism?

1 - increased cortisol in the brain
2 - decreased cortisol in the brain
3 - decreased depolarisation and anticholinergic
4 - increased histamine and anticholinergic

A

1 - increased cortisol in the brain

  • causes atrophy of hippocampus
64
Q

Tricyclic antidepressant (anti-cholinergic) are associated with delirium. What is the suspected mechanism?

1 - increased cortisol in the brain
2 - decreased cortisol in the brain
3 - decreased depolarisation and anticholinergic
4 - anticholinergic

A

4 - anticholinergic

  • causes low levels of acetylcholine
65
Q

Anti-Parkinson are associated with delirium. What is the suspected mechanism?

1 - increased dopamine
2 - decreased cortisol in the brain
3 - decreased depolarisation and anticholinergic
4 - anticholinergic

A

1 - increased dopamine

66
Q

Oxybutynin, tolterodine, solifenacin are associated with delirium. What is the suspected mechanism?

1 - increased dopamine
2 - decreased cortisol in the brain
3 - decreased depolarisation and anticholinergic
4 - anticholinergic

A

4 - anticholinergic

  • all 3 medication are used to treat an overactive bladder
67
Q

Which of the following tests should be used for assessing a chronic cognitive impairment like dementia?

1 - MMSE - Mini-mental state examination
2 - AMTS – Abbreviated mental test score
3 - SQID – Single question in delirium
4 - Short CAM – Confusion assessment method
5 - MOCA – Montreal cognitive assessment

A

1 - MMSE - Mini-mental state examination

5 - MOCA – Montreal cognitive assessment

68
Q

Which of the following tests can be a good tool for screening for cognitive impairment, but is unable to distinguish between dementia and delirium?

1 - MMSE - Mini-mental state examination
2 - AMTS – Abbreviated mental test score
3 - SQID – Single question in delirium
4 - Short CAM – Confusion assessment method
5 - MOCA – Montreal cognitive assessment

A

2 - AMTS – Abbreviated mental test score

69
Q

Which of the following tests are recommended to be used by NICE in a patient with suspected delirium?

1 - MMSE - Mini-mental state examination
2 - AMTS – Abbreviated mental test score
3 - SQID – Single question in delirium
4 - Short CAM – Confusion assessment method
5 - MOCA – Montreal cognitive assessment

A

4 - Short CAM – Confusion assessment method

  • 4-AT (SIGN) can also be useful
70
Q

The 4-AT (SIGN) can also be useful tool when assessing a patient for suspected delirium. It has 4 sections, which of the following is not one of them?

1 - alertness
2 - attention
3 - personal details
4 - mood
5 - acute change in cognition/fluctuations

A

4 - mood

71
Q

The Short CAM is the tool recommended by NICE and used in hospitals when assessing a patient for suspected delirium. It has 4 sections, which of the following is not one of them?

1 - disorganised thoughts
2 - inattention
3 - personal details
4 - consciousness
5 - acute change in cognition/fluctuations

A

3 - personal details

72
Q

Which of the following is NOT part of the Multifactorial management of patients with delirium?

1 - correct sensory impairments
2 - Re-orientate including preserving sleep wake cycle
3 - Reduce sensory distractions
4 - optimise hydration, bowels and bladder function
5 - prescribe new medications to treat delirium
6 - Maintain mobility safely
7 - Undertake a comprehensive medication review

A

5 - prescribe new medications to treat delirium

73
Q

Which of the following is NOT part of the Multifactorial preventative approach in patients with delirium?

1 - Regular orientation
2 - Early mobilization
3 - Sleep hygiene
4 - Minimize use of psychotropic drugs
5 - Correct sensory impairments
6 - Maximise psychotropic drug use
7 - Correct hydration

A

6 - Maximise psychotropic drug use

  • preventative measures can reduce delirium incidence by up to 33%
74
Q

What is a this is me card?

1 - new digital ID card
2 - new digital hospital ID
3 - card for patient at risk of cognitive impairment with preferences

A

3 - card for patient at risk of cognitive impairment with preferences

75
Q

Although sedatives and antipsychotics should generally not be used in patients with delirium, there is generally one exception, which is what?

1 - conservative measures have failed
2 - current antipsychotic are not work
3 - in the evening as fewer staff
4 - when family request them

A

1 - conservative measures have failed

  • used at the lowest dose for the shortest time
76
Q

Although sedatives and antipsychotics should generally not be used in patients with delirium, but when conservative measures have failed they can be used at the lowest dose for the shortest time. Which antipsychotic medication do NICE recommend?

1 - Lithium
2 - Morphine
3 - Haloperidol
4 - Levothyroxine

A

3 - Haloperidol

  • inhibits D2 receptors, essentially reducing dopamine
  • contraindicated in Parkinsons disease and Lewy Body Dementia
77
Q

Although sedatives and antipsychotics should generally not be used in patients with delirium, but when conservative measures have failed they can be used at the lowest dose of Haloperidol can be used. Which 2 groups of patients should Haloperidol NOT be used in though?

1 - Parkinsons disease
2 - Acute kidney Injury
3 - Lewy body dementia
4 - Congestive heart failure

A

1 - Parkinsons disease
3 - Lewy body dementia

  • consider using benzodiazepines instead: Diazepam, Lorazepam, Chlordiazepoxide
78
Q

Although sedatives and antipsychotics should generally not be used in patients with delirium, but when conservative measures have failed they can be used at the lowest dose for the shortest time. NICE recommend the use of Haloperidol. What other class of medication can also be helpful?

1 - Benzodiazepines
2 - Antiepileptics
3 - Bisphosphonates
4 - Thyroid hormones

A

1 - Benzodiazepines

  • binds GABA receptor and increases Cl- influx into cells
79
Q

Melatonin can sometimes be used as a treatment for delirium. When should it be prescribed?

1 - at night
2 - during the day
3 - when patient has reversal of sleep wake cycle
4 - if patient becomes angry

A

3 - when patient has reversal of sleep wake cycle

80
Q

When a patient has delirium, what is the average recovery time?

1 - 3 days
2 - 7 days
3 - 3 weeks
4 - 2 months
5 - 6 months

A

2 - 7 days

81
Q

The average time for recovery from delirium is 7 days. However, what % of patients will still have symptoms at 3 months?

1 - 10%
2 - 23%
3 - 33%
4 - 5-%

A

3 - 33%

82
Q

How long must a patients delirium symptoms last before a diagnosis of a chronic cognitive impairment is made?

1 - 1 month
2 - 3 months
3 - 6 months
4 - 1 year

A

3 - 6 months

83
Q

If a patients delirium symptoms last >6 months they will be diagnosed with a chronic cognitive impairment. Where should this diagnosis be made?

1 - acute hospital
2 - tertiary hospital
3 - home or memory clinic
4 - GP practice

A

3 - home or memory clinic

A. MLA Map Medicine of Older Adults (3 decks)

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