Delirium

Question 1

***What are the predisposing risk factors for delirium in elderly patients?

Answer 1

• Advanced age
• Dementia
• Functional impairment in ADLs
• Medical comorbidity
• History of alcohol abuse
• Male sex
• Sensory impairment (↓ vision, ↓ hearing)

Question 2

***What are the precipitating risk factors for delirium in elderly patients?

Answer 2

• Acute cardiac events
• Acute pulmonary events
• Bed rest
• Drug withdrawal (sedatives, alcohol)
• Fecal impaction
• Fluid or electrolyte disturbances
• Indwelling devices
• Infections (esp. respiratory, urinary)
• Medications
• Restraints
• Severe anemia
• Uncontrolled pain
• Urinary retention
• Post-Op (highest in hip fx)

Question 3

***What is the BEST tx for delirium?

Answer 3

prevention!

Question 4

What are the interventions to prevent delirium?

Answer 4

• Interventions for cognitive impairment, sleep deprivation, immobility, sensory impairment, dehydration
• Focus on non-drug approaches (e.g., sleep protocol involving warm milk, back rubs, soothing music)
• Limit or avoid psychoactive and other high-risk meds

Question 5

What are the interventions to prevent post-op delirium?

Answer 5

-Peak onset is on 2nd postoperative day (usually not sedated anymore)
-Associated with postoperative pain, postoperative anemia, use of benzodiazepines and opioids.
-Higher incidence in cardiac surgeries and emergent hip fracture repair.
-Recommended:
• Limit sedation
• Provide adequate analgesia
• Transfuse high-risk patients

Question 6

How do you recognize and diagnose delirium?

Answer 6

• **1. Confusion Assessment Method (CAM)-Most useful clinically
  2. DSM-IV Criteria-Precise but hard to apply
  3. History, physical, labs are helpful (imaging, EEG, and CSF rarely helpful)

Question 7

***What is the Confusion Assessment Method (CAM) of diagnosis?

Answer 7

> 95% sensitivity and specificity.
Requires features 1 and 2 and either 3 or 4:
1. Acute change in mental status and fluctuating course
2. Inattention (squeeze hand when you hear certain letter ie “A” in “SAVEAHAART”) > 2 errors
3. Disorganized thinking:
• Yes/No questions = Will a stone float on water?
• Command = hold up this many (2) fingers; now do the same thing with the other hand (see if they can)
4. Altered level of consciousness

Question 8

What is the DSM-IV Criteria for diagnosing delirium?

Answer 8

• Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
• Change in cognition (e.g., memory deficit, disorientation, language disturbance) or a perceptual disturbance not better accounted for by existing dementia
• Development over a short time (hours to days) and fluctuation during the day
• Evidence from history, physical, or labs that disturbance is direct physiologic consequence of a medical condition

Question 9

What are the possible types of delirium?

Answer 9

1. Hyperactive or agitated delirium
2. Hypoactive delirium
3. Mixed
4. Other: emotional, psychotic and sundowning symptoms

Question 10

How do you treat elderly patients with delirium?

Answer 10

• Treat the underlying disease (discontinue likely medications)
• Address contributing factors
• Monitor pain
• Monitor urinary retention
• Monitor fecal impaction
• Provide “social” restraints
• Consider a sitter or allow family to stay in room
• Discourage daytime napping (normalize sleep-wake cycle)
• Avoid physical or pharmacologic restraints

Question 11

***What is Agitated Delirium? How should you manage it?

Answer 11

-***Medical emergency (d/t stress of CV system)
-Interferes with care, prolongs hospital stay and worsens outcome.
-Use low-dose halperidol:
• Monitor for torsades de pointes
• Don’t use continuous IV sedation or benzodiazepines