Delirium Flashcards
What are the five areas of disturbance assoc. with delirium?
- impairment consciousness
- psychomotor disturbance
- disturbance of cognition
- disturbance of sleep/wake cycle
- emotional disturbance
does everyone with delirium have the same degree of impairment of consciousness?
-no: this is a continuum
Clouding/drowsiness/stupor/coma
What kind of cognitive disturbance can occur in delirium? (4)
- disorientation to TPP
- impaired memory and attention
- impaired thinking
- perceptual disturbance: hallucinations/illusions
Describe the pschomotor disturbance found in delirium?
Hypoactive: confusion/sedation
Hyperactive: agitation/disorientation/perceptual disturbance/aggression
Mixed: fluctuating sx of both types
Describe the sleep disturbance that occurs in delirium? (5)
- insomnia
- sleep loss
- reversal sleep/wake cycle
- sundowning
- disturbing dreams/nightmares
What affective disturbances occur in delirium? (7)
- depression
- anxiety
- fear
- irritability
- euphoria
- apathy
- perplexity
What are the nature of symptoms in delirium?
- Rapid onset
- fluctuating course
What blood/simple tests are included in a patient with suspected delirium?
- urinalysis
- FBC/U+E/LFTs
- Thyroid
- Blood glucose
- CRP
- B12/Folate
What methods of assessment exist for delirium?
- confusion assessment method
- 4AT
What is the confusion assessment method?
Feature 1 Acute onset and fluctuating course
This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions:
1. Is there evidence of an acute change in mental status from the patient’s baseline?
2. Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase or decrease in severity?
Feature 2 Inattention
This feature is usually obtained by interacting with the patient, but may also be reported by family members or staff and is shown by a positive response to the following question:
3. Did the patient have difficulty focusing attention, for example being easily distractible or having difficulty keeping track of what was being said?
Feature 3 Disorganised thinking
This feature is usually obtained by interacting with the patient, but may also be reported by family members or staff and is shown by a positive response to the following question:
4. ‘Was the patient’s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?’
Feature 4 Altered level of consciousness This feature is obtained by observing the patient and is shown by any answer other than ‘alert’ to the following question: 5. Overall, how would you rate this patient’s level of consciousness? • Alert (normal) • Vigilant (hyperalert) • Lethargic (drowsy, easily aroused) • Stupor (difficult to arouse) Coma (unarousable)
What is the 4AT score?
[1] ALERTNESS
This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy
during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with
speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating.
Normal (fully alert, but not agitated, throughout assessment) 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4
[2] AMT4
Age, date of birth, place (name of the hospital or building), current year.
No mistakes 0
1 mistake 1
2 or more mistakes/untestable 2
[3] ATTENTION
Ask the patient: “Please tell me the months of the year in backwards order, starting at December.”
To assist initial understanding one prompt of “what is the month before December?” is permitted.
Months of the year backwards Achieves 7 months or more correctly 0
Starts but scores <7 months / refuses to start 1 Untestable (cannot start because unwell, drowsy, inattentive) 2
[4] ACUTE CHANGE OR FLUCTUATING COURSE
Evidence of significant change or fluctuation in: alertness, cognition, other mental function
(eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs
No 0 Yes 4
what are the four principles of managing delirium?
1: identify and treat cause
2: manage environment - make staff aware/reality orientation/correct sensory impairments
3: prescribe: antipsychotics (consider practical management first) standard is haloperidol 1-10mg (0.5mg if elderly)
4: review frequently
What is NHS tayside protocol for prescribing in delirium?
What about for a patient with parkinsons/lewy body dementia/neuroleptic sensitivity?
What is important to remember for alcohol/sedative withdrawal patients?
- Haloperidol 0.5-5mg orally, then IM up to 10mg in 24hrs.
- For parkinsons/lewy body dementia/neuroleptic sensitivity use lorazepam 0.5-2mg up to twice in 24hours
- one drug at a time, start at a low dose and increase
- In alcohol/sedative withdrawal remember regular BZD’s prescribing thereafter
What is the prognosis for delirium?
- mean duration: 1-4wks
- Minority can become chronic
- risk factor for developing persistant cognitive impairment and depression
Which affective disorder commonly presents after stroke?
Post-stroke depression
- most common neuropsychiatric complication of stroke
- up to 1/3 stroke patients have major depression
