Delirium Flashcards
delirium is characterized by disturbed _____ with decreased ____ and _____ awareness
disturbed consciousness
decreased attention
environmental awarness
does delirium come on rapidly or gradually? is it persistent throughout the day?
comes on rapidly
fluctuates throughout the day
what does the prodromal phase of delirium often look like?
fatigue, daytime somnolence, decreased concentration, irritability, restlessness, anxiety, mild cognitive impairment
does a patient with delirium ever have periods of lucidity?
yes! periods of lucidity where the patient can function at baseline
what time of day is delirium worst?
night
delirium is often associated with these four features
1) language difficulties (slow or slurred, word finding difficulties)
2) impaired memory
3) disorientation
4) hallucinations (visual, auditory, tactile)
what are the 3 clinical variants of delirium?
1) hyperactive
2) hypoactive
3) mixed
what two features MUST be included in the confusion assessment method (CAM)?
feature 1 = acute onset, fluctuating course
feature 2 = inattention (is pt having difficult keeping track of what’s been said?)
in addition to feature 1 and 2, ONE of these two features must be present to confirm dx of delirium
feature 3 = disorganized thinking (rambling, unclear)
feature 4 = altered level of consciousness (hyperalert, lethargic, stupor, etc)
which medications have the propensity to precipitate delirium?
1) anticholinergics
2) anti-inflammatories
3) benzos (use or withdrawal)
4) ETOH (withdrawal)
5) CV meds – digoxin, diuretics
6) lithium
7) opioid antagonists
in terms of GI/GU, what do we worry about that could precipitate delirium?
constipation/fecal impaction or post-op urinary retention
what is the in-hospital mortality rate of delirium?
25-33 percent
similar to sepsis
approximately ____ percent of medical patients experience delirium at some point during hospitalization
30 percent
financially, why do we worry about delirium?
costs billions of dollars in yearly healthcare costs in US
patient has acute episode of delirium in the hospital, where are they most likely to go after this?
nursing home
does one episode of delirium put you at risk for more?
yes
______ often goes unrecognized prior to the onset of delirium
dementia
what neurotransmitter is thought to play a critical role in delirium?
acetylcholine
what are the 3 pharmacologic or physiologic processes that decrease ACH synthesis, leading to delirium?
1) anticholinergic drugs = decrease ACH
2) hypoxia, hypoglycemia, thiamine deficiency = decrease ADH synthesis
3) alzheimer’s characterized by loss of cholinergic neurons (risk of delirium)
what are the two components that give way to an episode of delirium?
1) insult to vulnerable brain
2) underlying neurodegenerative disorder
therefore – delirium sometimes brings out previously unrecognized dementia or other brain disorders
when do we consider pharmacologic therapy in delirium?
ONLY when patient is at risk for harming him/herself
what is the DOC in delirium?
haloperidol
what do you need to monitor while patient is on haloperidol?
QTc prolongation
if patient has been on haldol for a week, what do you need to do?
switch to other antipsychotic agent to avoid extra-pyrimidal symptoms
quetiapine (seroquel) is the DOC for delirium in these 4 populations
1) lewy body dementia
2) parkinsons dementia
3) AIDS-related dementia
4) HX of EPS
what do we do if delirium is due to ETOH or benzo withdrawal?
give benzos titrated to effect
what are the 2 things we do during ETOH withdrawal? (one is a tool, one is a med in addition to benzos)
1) CIWA
2) thiamine to avoid wernicke’s
should we restrain patients who are becoming agitated or aggressive?
NO – can precipitate delirium
is delirium reversible?
yes! potentially, but may require weeks or months to fully resolve
