Delirium Flashcards
Define delirium
Acute confusional state
What does delirium effect?
Affects global cognitive function
Including memory, orientation, language, perception and visuospatial skills (all domains of cognitive function)
What are some other features of delirium?
Other features:
Psychomotor disturbance
Altered sleep-wake cycle
Emotional lability –> outbursts of crying, laughing, angry quickly
Describe the DSM-5 criteria of Delirium
Acute onset
Disturbance in attention, awareness, and cognition
Fluctuates in severity
Attributable to an underlying cause (Can occur secondary to infections but can be many causes)
Describe the prevalence of delirium
Delirium affects ~11-42% of medical inpatients
Especially common among older adults
1/3 of medical inpatients > or = to70 years of age
Describe delirium and surgery
Most common surgical complication
15-25% after elective surgery
50% after major, non-elective surgery
Describe the sigificance of delirium?
Poor prognostic indicator
Delirium is associated with1:
2 x ↑ risk of death
2.5 x↑ risk of discharge to higher level of care
12.5 x ↑ risk of developing dementia
↑ length of hospitalization (5-10 days)
Sustained functional decline 6 months after admission2
Describe the interplay between dementia and delirium
Do not know if delirium episode changes something permanently that predisposes them to dementia or reveals underlying mechanism that increases one’s predisposition to dementia
Describe the risk factors for Delirium
underlying vulnerability + stressors
Describe the prevalence of delirium stratified by age group
Delirium risk is higher in older adults
Describe the drugs that are risk factors for delirium
Muscle Relaxants –> Cyclobenzaprine, Baclofen, Methocarbamol
CBZ, Phenyton –> Higher serum concnetrations
Gabapentin/Pregab —> Not used for anticonvulsnats; high prevalence in pain –> Same effecrs
Corticosteorids – > 40 mg for a COPD exacerbation –> higher doses of CS’s
Psychoactive NSAID’s –>Indomethacin
Digoxin –> Higher doss and serum concetn
IS delirium often recognized? Why or why not?
Only 12-35% of delirium cases are recognized1
Underrecognized and under-diagnosed
What is the most useful bedside method for assessing a suggestive diagnosis of delirium? How is it scored?
Describe the subtypes of delirium
Might have one or switch between two
Which subtype of delirium is most likely to be recognized?
Hyperactive more likely to be recognized –> Doing something –> Getting out of bed, hitting nurses
–> More likely to be diagnosed with delirium
Hypodelirium –> Less diagnosed –> Hard to arouse them or not coherent –> Laying in bed, sedated
Describe a study looking at the prognosis of delirium?
Duration?
Outcomes?
o Causes: 58% due to infection, 36% due to metabolic, 18% drug-induced
o Duration: mean of 16 days, but ranges 2-96 days
o Outcomes: 48% mortality (70% with infection),12% persisted, 33% resolved
Is it appropriate to diagnose someone with dementia after a period of delirium?
Not appropriate to assess someone or diagnose dementia after a period of delirium
Can last a long time (2-96 days)
Describe the differences between delirium and dementia
Describe the strategies for delirium prevention
Stopping meds/substace withdrawal delirium –> Nicotine replacement therapy –> Get outside to smoke
Describe the management of delirium
Thorough medical evaluation for underlying cause –> Not ruling out medications just cause you diagnosed a UTI
Medications –> least important –> Minor role to play in tx of delirium
In geriatrics, what is the severity of delirium?
Delirium should be considered a Medical Emergency in geriatrics
URGENT CARE
Worse outcomes longer it continues untreated
What are some underlying causes of delirium?
Readily reversible causes (e.g., hypoxia, hypo/hyperglycemia, hyponatremia, hyperkalemia)
Infection
Neurologic (stroke)
Medication induced adverse effects, overdose, supratherapeutic levels
Toxicology (alcohol or substance use/withdrawal)
Metabolic
Cardiopulmonary
Environmental factors (lack of sleep, unfamiliar environment, lack of hearing/vision aids)
Other: pain, urinary retention, constipation
Pharmacological Therapy is only indicated when:
Are anti-psychotics an on label indication for delirium?
Off-label
Which medications are used for delirium?
Haloperidol: Conventional – Theoretical advantage of being in an injectable form
Haloperidol: Reasonable for a day or 2 of usage
Safety –> Higher risk of EPS in adults with continuous use over a long period of time
If using AP for more than 5 days: Switch haloperidol to atypical AP
Cannot not appropriately stop Benzo –> Tirate dose down –> precipitate higher likelihood of return and worsen delirium (longer o recovr)
Haloperidol Usage for Delirium
Conventional drug of choice
Available in oral and parenteral formulations
If longer treatment duration is required, switch to atypical to ↓ risk for EPS
Are atypical anti-psychotics used for delirium? Comparisons?
Atypical Antipsychotics (olanzapine, quetiapine, risperidone)
↓ risk for EPS but ↑ risk for orthostatic hypotension
Olanzapine is the most anticholinergic
Quetiapine agent of choice for individuals with Parkinson’s disease or Lewy Body Dementia
Quetiapine has the elast DA blocking –> Parkinson’s dx lack of DA neurons in the brain
Quetiapine least DA blocking effect –> Clozapine can also be used but ade make use limited in acute setting
Describe the differences in antipsychotics
Warnings of atypical antipsychotics
Atypical antipsychotics have a black-box warning for use in individuals with dementia
↑ risk of mortality (~1.6x)
Not seen in studies of short-term use for delirium (3-7 days
