Delirium Flashcards
What is the first diagnostic criteria for delirium?
- Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduce ability to focus, sustain or shift attention
What is the second diagnostic criteria for delirium?
- A change in cognition (i.e. memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre existing established or evolving dementia
What is the third diagnostic criteria for delirium?
- The disturbance develops of a short period of time (h-> d) and fluctuates
What is the fourth diagnostic criteria for delirium?
- There is evidence from the Hx, PEx or Ix that disturbance is caused by the direct physiological consequences of a general medical condition
What are the DSM IV diagnostic criteria for delirium?
- Disturbance of consciousness, esp attention
- Change in cognition or perceptual disturbance
- Short time period, fluctuates
- Evidence result of medical condition
EEG / neuroimaging of pts with delirium?
- Reduced cerebral oxidative metabolism ->
- altered neurotransmitter levels in prefrontal and subcortical areas
- esp in non-dominant cerebral hemisphere
Pathogenesis of delirium theories?
- Cholinergic deficiency and dopaminergic excess
- cytokines and chronic stress via activation of HPA axis
What are common delirium predisposing factors?
- Advanced age
- Impaired cognition
- Previous Hx delirium
- Depression
- Functional disability
- Visual and hearing impairment
- Dehydration
- Malnutrition
- Drugs
- Presence of chronic disease
What are common precipitating factors of delirium?
- Drugs
- Infection (esp chest, UTI)
- Constipation
- Electrolyte disturbance
- Organ failure
- Primary neurological disease
- Surgery
- Environmental inc hospital interventions i.e. IDC
- Sleep deprivation
What is delirium?
Abrupt in onset with fluctuating symptoms of inattention, disorganised thinking, impaired cognition, altered conscious state, altered sleep wake cycle, perceptual and emotional disturbances.
What are the variants of delirium?
- Hyperactive (25%): agitation and vigilance
- Hypoactive (25%): quiet and withdrawn
- Mixed (35%): fluctuations and lucid intervals
- Normal psychomotor activity (15%)
What non cognitive changes can delirium precipitate?
- Gait and balance disturbance
- Falls
- Functional decline
- Urinary and faecal incontinence etc
Is delirium readily identified in the hospital setting?
No. Often missed.
Routine cognitive assessment in elderly hospital pts; consider a vital sign.
What is the CAM?
- Acute onset and fluctuating course
- Inattention
- Disorganised thinking
- Altered LoC
Protocol for prevention of delirium in NoF pts?
- Geriatrician involvement
- Early surgery
- Analgesia
- Oxygen delivery
- Fluid management
- Medication reviews
- Bowel and bladder function
- Nutrition
- Early mobilisation
- Prevention and treatment of post op complications
What are the aims of delirium Mx?
- Identify and Mx predisposing factors and precipitants promptly
- Provide supportive care and prevent complications
- Treat neuropsych manifestations
- Frequent reviews to monitor progress
Supportive care delirium Mx?
- Protect airway
- Maintain hydration and nutrition
- Positioning and mobilisation to prevent pressure sores and DVT
- Avoid restraints
Non pharm Mx delirium?
- Calm and comfortable environment
- Correct dehydration, malnutrition, sensory deficits
- Involve family
- Calendars, clocks, schedules to orient
- Simple instructions, avoid jargon
- Decreased room and staff changes
- Avoid sleep deprivation
- Avoid restraints and immobilising devices (e.g. IDC)
- Encourage mobility and self care
Pharm Mx when?
- Safety pt / other threatened
- Sx prevent delivery essential therapy and care
Pharm Rx in delirium?
- Antipsychotics: best evidence = haloperidol
- Benzo: drug and EtOH withdrawals
Drugs types likely to cause delirium?
Psychoactives and drugs crossing BBB; anticholinergic effects (NB antichol of some drug metabolites add to anticholinergic burden)
Drug classes likely to cause delirium?
- Antiparkinsonians
- Benzodiazepines
- Lithium
- Anti depressants
- Anti-psychotics
- Anti-convulsants
- Antiarrhythmics
- Antihypertensives
- Histamine2 receptor antagonists
- Corticosteroids
- Opiates
- NSAIDs
- OTCs / CAMs
- Anthistamines
- Antispasmodics
Routine screen for delirium if no obvious cause?
-FBE / UEC / LFTs
-CMP
-Glucose
-Troponins
-ESR, CRP
-O2 Sat
-MSU if UA abnormal
-CXR
-ECG
Consider: blood culture, TFTs, B12/ folate, ABGs, CTB, LP, EEG.
Benzos in delirium?
For EtoH and drug withdrawal, not recommended in deliruim as can worsen.
- Use agents with short T1/2 and no active metabolites (e.g. lorazepam 0.5mg; oxazepam 7.5mg)
- IM Midazolam (1mg) for excessive agitation not responding to neuroleptics or when inappropriate (i.e. EPSE)
