Delirium Flashcards
What are the risk factors for delirium?
Dementia Multiple comorbidities Physical frailty Older age Sensory impairments
What are the first line investigations?
WCC/ CRP Electrolytes LFTs Glucose Thyroid function tests Chest x-ray Urinalysis ECG
What are the second line investigations?
Serum calcium, B12, folate Arterial blood gas (hypoxia, acidosis) Specimen cultures (blood, sputum) CT/MRI head Electroencephalogram Toxicology screen Bladder scan (urinary retention) Lumbar puncture
What are the precipitating factors?
drug initiation medical illness systemic infection metabolic derangement surgery pain brain disorders systemic organ failure
Important ddx of delirium?
Dementia
What are the key features of delirium?
Acute onset Fluctuating course Disorganised thinking Altered level of consiousness Inattention and distractibility Underlying medical cause (usually)
What is the presentation of delirium?
an acute disorder associated with medical illness, medications etc.
Impaired cognition associated with an affective disorder or psychosis
What is the onset and duration of delirium?
Acute onset
Lasts days/weeks
What is the first step in managing delirium?
treat underlying cause
examples
- polypharacy –> drug review
- pain –> analgesia
- constipation –> laxatives
- infection –> abx
- correct electrolytes
What is the second step in managing delirium?
involve family soft lighting clocks and calendars sleep hygiene/ promote night time sleeping correct sensory impairment keep mobile and active avoid multiple room/ward moves minimise provocation (noise, restraints)
What should be monitored in delirium?
Vital signs Bowels Nutrition and hydration Pressure areas Electrolytes Response to antibiotics Re-explore diagnosis if not improving
What is the prevalence of delirium?
30% of older hospitalised medical patients
10-15% of surgical patients
How is the diagnosis of delirium made?
AMT on admission to screen - <8/10 should lead to more detailed evaluation
The confusion assessment method is sensitive and specific for delirium - following criteria:
acute onset and fluctuating course AND
inattention AND
disorganised thinking OR altered level of consciousness
Delirium may be hyperactive, hypoactive or mixed
What is the ABC approach to managing delirium?
Antecedents - that trigger difficult behaviours in the context of the delirium
Behaviours - what is the patient trying to achieve? Can you help them achieve it safely?
Consequences - of the the behaviour - is it causing any harm? What is the harm?
Should drugs be used in management?
Drugs should be avoided and only used if other interventions have been tried and failed
Which drugs should be used?
Haloperidol and lorazepam - orally or IM
Which drug is preferred in parkinson’s disease or levy body dementia and why?
Lorazepam is preferred due to the extrapyramidal SEs of haloperidol
What are the two indications for use of sedative drugs?
- Rapid tranquillisation of an agitated patient where there is immediate risk of harm or danger
- Short term control of distress
What does should the drugs be used at?
The lowest possible effective dose
How does delirium effect capacity?
- It impairs capacity
- Decisions should be delayed until after delirium resolves
- if decision cannot wait then treatment decisions should be made in the patients best interests
What is the prognosis for a patient with delirium?
Percentage which persist at 2 weeks/1 month/never recover
40% persist at 2 weeks
33% persist at 1 month
20% never recover
some patients (particularly with dementia) will not reach their pre-delirium level of function
What are the consequences of delirium?
Increased mortality - 60% more likely at one year
Prolonged hospital admission
Higher rate of institutionalisation
An eightfold increased risk of going on to develop dementia within 3 years
