Delirium Flashcards
What is delirium?
acute confusional state
-acute onset, develops rapidly over hours-days
-serious medical problem, much more than a nuisance effect
What does delirium affect?
global cognitive function
-memory, orientation, language, perception, visuospatial skills
Asides from confusion, what are some other features of delirium?
psychomotor disturbance
altered sleep-wake cycle
emotional lability
What is the definition of delirium as per the DSM-5?
acute onset
disturbances in attention, awareness, and cognition
attributable to an underlying cause
fluctuates in severity
Describe the prevalence of delirium.
affects ~11-42% of all medical inpatients
more common in older adults
-1/3 of medical inpatients > 70 years of age
-most common surgical complication
What is the significance of delirium?
poor prognostic indicator
associated with:
-2 x increased risk of death
-2.5 x increased risk of discharge to higher level of care
-12.5 x increased risk of developing dementia
increased length of hospitalization (5-10 days)
sustained functional decline 6 months after admission
What is the etiology of delirium?
underlying vulnerability + stressors
What are some predisposing factors for delirium?
increased age
dementia
functional impairment (baseline)
multimorbidity
others
-decreased hearing/vision, mild cognitive impairment, depression, alcohol/drug use
What are some precipitating factors for delirium?
drugs
surgery/trauma
infection
pain
anemia
exacerbation of chronic disease
bedridden
What are examples of drug that can increase risk of delirium?
the worst:
-anticholinergics (TCAs, 1st gen AH, muscle relaxants, 1st gen APs, benztropine)
-benzodiazepines
-opioids
also bad:
-anticonvulsants (CBZ, phenytoin, topiramate, gabapentinoids)
-dopamine agonists
-amantadine
-THC products
less likely but possible:
-corticosteroids
-psychoactive NSAIDs (indomethacin)
-digoxin
-CBD products
What is the most useful bedside method for diagnosing delirium?
Confusion Assessment Method (CAM)
requires 1+2 with either 3 or 4:
1. acute changes in mental status with fluctuations
2. inattention
3. disorganized thinking
4. altered level of consciousness
What are the subtypes of delirium?
hyperactive delirium subtype
-combative, agitated, restless
mixed delirium subtype
-fluctuating between the other two
hypoactive delirium subtype
-drowsy, somnolent, unarousable
Differentiate delirium and dementia.
delirium:
-onset: acute (hours-days)
-course: fluctuating
-decreased level of consciousness: may be present
-attention: impaired
-hallucinations: common
dementia:
-onset: chronic (months)
-course: progressive
-decreased level of consciousness: absent
-attention: preserved until end-stage
-hallucinations: rare until later stages
What are some strategies to prevent delirium?
orientation
-use calendars, clocks
-encourage use of glasses, hearing aids
-accommodate visitors
-promote regular sleep-wake cycle
mobilization
-physical therapy
-avoid unnecessary lines, catheters, restraints
medication review
-reassess use of high-risk medications
-medication/substance withdrawal
-pain control, bowel + bladder function
hydration and nutrition
-maintain or optimize
How is delirium managed?
- identify and manage underlying cause(s)
-most important step - initiate or continue supportive strategies
- medications
-only if necessary, smallest role
What are some supportive strategies for treating delirium?
treat the underlying condition
manage pain and other symptoms
encourage mobilization
re-orientation, cues
maintain sleep-wake schedule
de-escalation for agitated individuals
system-level interventions:
-minimize time spent in ED
-trained volunteers to calm, provide re-orientation
-low beds
-non-slip floors or socks
When can pharmacological therapy be considered for delirium?
patient is in significant distress from their symptoms
patient poses a safety risk to self or others
patient is impeding essential aspects of care
How are medications used for delirium?
off-label
What is the first line pharmacological option for delirium?
antipsychotics
How do we choose an antipsychotic for delirium?
based on side effect profile, patient factors, and availability
similar efficacy among agents
How are antipsychotics dosed for delirium?
start with low doses and titrate to effect q30min
prn doses thereafter
Which class of medications should be avoided in a patient experiencing delirium?
benzodiazepines
-except in alcohol-withdrawal delirium, terminal delirium
What is the conventional drug of choice for delirium?
haloperidol
-if longer duration of treatment needed, switch to atypical to decrease EPS risk
What is the benefit of atypical antipsychotics compared to typicals?
decreased EPS risk BUT increased orthostasis risk
Which atypical antipsychotic is the most anticholinergic?
olanzapine
Which atypical antipsychotic is used for delirium in patients with Parkinsons or Lewy Body Dementia?
quetiapine
-least DA blockade
What is a black box warning of atypical antipsychotics?
dementia
What is the role of the pharmacist in delirium prevention and management?
deprescribe medications known to increase delirium risk
assess for and manage pain, constipation
ensure judicious use of antipsychotics for delirium
