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Medicine for the elderly > Delirium > Flashcards

Delirium Flashcards

1
Q

What is delirium?

A

An acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute illness, surgery, trauma or drugs

This involves a disturbance in attention and cognition and tends to fluctuate during the day

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2
Q

Why is delirium important?

A

It is associated with increased levels of morbidity and mortality

There is also an increased risk of complications such as falls, increased lengths of hospital stays, pressure sores, dehydration and malnutrition

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3
Q

How common is delirium in hospital?

A

20% of patients in acute adult general medical wards will have a diagnosis of delirium

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4
Q

What is the supposed pathophysiology of delirium?

A

There is variable derangement of multiple neurotransmitters, particularly ACh

There is also some contribution from direct toxin insults (Drugs, hypoxia, hyponatraemia, low glucose) and irregular stress responses (Cortisol, prostaglandins, cytokine release)

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5
Q

What are some risk factors for delirium?

A
  • Elderly
  • Pre-existing cognitive impairment
  • Post-operative
  • Sensory impairment
  • Previous delirium
  • Drugs/Alcohol dependence
  • Depression
  • Polypharmacy
  • Multiple co-morbidities (E.g. Frailty, Parkinson’s, CVD)
  • Critical care admission
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6
Q

What are the common causes of delirium?

A

D - Drugs/medication

E - Electrolyte disturbances

L - Lack of drugs (Withdrawal)

I - Infection

R - Reduced sensory input or pain

I - Intracranial pathology (Stroke/Subdural)

U - Urinary retention/constipation

M - Metabolic (AKI, Hypoglycaemia, hypothyroid, B12/Folate, Calcium)

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7
Q

What are the main features of delirium?

A
  • Acute onset
  • Fluctuating course
  • Altered conscious level (Hypo or hyperactive)
  • Inattention or decreased awareness
  • Disorganised thinking
  • Not explained by pre-existing or evolving neuro-cognitive disorder or coma
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8
Q

What are the 2 sub-types of delirium?

A

Hyperactive
Hypoactive

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9
Q

What are the features of hyperactive delirium?

A
  • Agitated
  • Aggressive
  • Wandering
  • Easy to diagnose
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10
Q

What are the features of hypoactive delirium?

A
  • Withdrawn
  • Apathetic
  • Sleepy
  • Coma
  • Easily missed
  • 2x mortality of hyperactive delirium
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11
Q

Who should be screened for delirium?

A

All patients over 65

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12
Q

What scoring tool is used to screen for delirium?

A

4-AT

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13
Q

What are the 4 stages of the 4-AT?

A
  1. Alertness
  2. AMT4 - Age, DOB, place, current year
  3. Attention (Reverse months)
  4. Acute change or fluctuation (Last 24 hours)
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14
Q

What are the 3 points of alertness in 4-AT?

A
  1. Normal (Fully alert but not agitated throughout) = 0
  2. Mild sleepiness for <10 seconds after waking = 0
  3. Clearly abnormal = 4
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15
Q

What are the 4 points of AMT4 in 4-AT?

A
  1. No mistakes = 0
  2. 1 mistake = 1
  3. ≥2 mistakes or untestable = 2
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16
Q

What are the 3 points of attention in 4-AT

A
  1. ≥7 months correctly = 0
  2. <7 months or refuses = 1
  3. Untestable due to inattention or drowsiness = 2
17
Q

What are the 2 points of acute change or fluctuation in 4-AT?

A
  1. No = 0
  2. Yes = 4
18
Q

What does a 4-AT of ≥4 suggest?

A

Possible delirium ± cognitive impairment

19
Q

What does a 4-AT of 1-3 suggest?

A

Possible cognitive impairment

20
Q

What does a 4-AT of 0 suggest?

A

Delirium unlikely

21
Q

What are the main management points for delirium?

A

Identify and treat cause
Non-pharmacological management of agitation (1st line)
Environmental measures
Explain diagnosis
TIME bundle
Follow-up

22
Q

What is the TIME bundle?

A

T - Think about possible triggers
I - Investigate and intervene
M - Manage
E - Explain

23
Q

What is involved in T of TIME bundle

A

Think about:
- Sepsis
- Blood glucose
- Medication history
- Alcohol history
- Urinary retention
- Constipation

24
Q

What is involved in I of TIME bundle

A
  • Start fluid balance chart
  • Bloods - FBC, U+E, LFT, CRP, TFT, Ca, Po4
  • Symptoms or signs of infection
  • ECG
25
Q

What is involved in M of TIME bundle?

A

Initiate treatment of all causes found

26
Q

What is involved in E of TIME bundle?

A
  • Document diagnosis of delirium
  • Explain to patient and family (Use delirium leaflet
27
Q

What are the sedation options for delirium patients with symptoms that threaten themselves or others?

A
  • Get senior advice, then:
    1. Haloperidol 0.5-1mg PO or IM if not taken orally (Avoid in Parkinsonism or Lewy-body ) - Max 5mg in 24 hours
    2. Lorazepam 0.5-1mg PO - Benzodiazepines can worsen or prolonge delirium

Medicine for the elderly (8 decks)

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