Delirium Flashcards
Types of delirium
Hypoactive (40%)
Hyperactive
Mixed
Describe hypoactive delirium
Apathy
Withdrawal
Lethargy
Reduced motor activity
Often goes unrecognised or mistaken as depression
Higher hospital stays and risk of pressure sores
he patient is quiet, withdrawn, lacks initiative and responds poorly to interaction
Describe hyperactive delirium
Increased motor activity
Agitation
Hallucinations
Challenging behavior
More likely to be recognised
Describe mixed delirium
Fluctuations between hypo and hyperactive, often during the course of a day
Sleep-wake disturbance
Aetiology of delirium
Infection Withdrawal Acute metabolic Trauma CNS pathology Hypoxia Deficiencies Endocrine Acute vascular Toxin Heavy metal
DSM-5 criteria of delirium
Disturbance of consciousness with reduced ability to focus, sustain or shift attention
Change in cognition that develops over a short period of time that is not better accounted for by a pre-existing, established or evolving dementia
Tendency to fluctuate during the course of the day, with disturbance of the sleep wake cycle
Evidence from history, examinations or investigations that the delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication
Describe what disturbance of consciousness means
reduced attention, which is the ability to focus, sustain or shift mental focus:
Distractibility
Drowsiness
Reduced vigilance
Other associated features of delirium
Delusions (fleeting, often paranoid, lack logic)
Emotional - anxiety, fear, deprsession
Motor - slowness, restlessness, agitation
Hallucinations - often formed
Cognitive deficits
Which cognitive deficits may be associated with delirium
Language difficulties: word finding
Speech - slurred, mumbling, incoherent or disorganised
Memory dysfunction - marked short-term memory impairment, disorientation to PPT
Perceptions - misinterpretationss, illusions, delusions and/or visual or auditory hallucinations
Constructional disability - cannot copy a cube
Clinical characteristics of delirium
Develops acutely (hrs to days)
Characterised by fluctuating level of consciousness
Reduced ability to maintain attention
Agitation or hyper-somnolence
Extreme emotional lability - crying/laughing
Cognitive deficits can occur
AMT < 8/10
Which examinations may help in assessing delirium?
Assess conscious level: GCS or AVPU
Cognitive function: AMT (<8 is abnormal)
Infection screen
Nutrition and hydration assessment
Constipation (rule out urinary retention and constipation - Abdo exam and DRE). Consider post-void bladder scan
Neurology - perform exam, including speech
What is the Confusion Assessment Method (CAM)
Assess 4 features:
Acute onset and fluctuating course (ask family members/nurse)
Inattention (easily distracted/cannot keep track)
Disorganised thinking (including slurred speech)
Altered level of consciousness (alert, vigilant, lethargic, stupor, coma)
What are the predisposing RF for delirium
Dementia Cognitive impairment Frailty Multiple co-morbidities >65yrs Sensory impairment (eg. vision) Current hip fracture Severe illness Polypharmacy Malnutrition Alcohol excess
What are precipitating risk factors for delirium?
Drug initiation/withdrawal Acute brain disease Surgery Metabolic abnormalities Systemic infection UTI Hyponatraemia Hypoxaemia Shock Anaemia Pain Orthopaedic or cardiac surgery ICU admission High number of hospital procedures
Ways of trying to prevent delirium
Keep orientated
Promote the familiar
Glasses, light and hearing aid for vision etc
Keep hydrated and well fed
REduce medication (avoid anti-cholinergic drugs and opiates)
Keep mobile and active
Promote night time sleep
Minimise provocation (noise, tubes, restraints)
