Delirium Flashcards
Causes of Delirium
Drugs (especially anticholinergic, hyponatr. from SSRI)
Emotional (depression or acute psychosis)
Low PO2 (PE, MI, anemia, stroke)
Infection
Retention of urine/feces
Ictal (especially partial complex seizures and absence)
Undernutrition (especially dehydration)
Metabolic (thyroid, hyperglycemia, B12, hyponatr, Liver/kidney)
Subdural hematoma
Describe CAM Diagnostic algorithm
- Acute onset and fluctuating course
- Inattention (say days of week backwards, easily distracted or not paying attention)
AND either:
3a. Disorganized thinking (paranoia, incoherence, unpredictable, illogical, hallucinations/illusions)
3b. Altered LOC (from -5 unarousable to +5 combative)
Risk factors/predisposing factors for delirium
dementia previous episodes functional impairment sensory impairment major organ system/comorbidities depression hx TIA/stroke ETOH use >75 anticholinergic medications current hip fracture
Precipitating factors for delirium
Drugs (anticholinergics, SSRIs) Polypharmacy use of physical restraints use of foley electrolyte imbalance (hyponatremia, hyperglycemia) surgery infection
What are the three presentation possibilities of folks with delirium?
hyperactive
hypoactive
mixed
Symptoms of delirium
- attention deficits (3 words, count backwards)
- disorganized thinking (people who live in glass houses shouldn’t throw stones eg)
- Disturbance in perception (hallucinations, illusions, delusions/paranoia) How are people treating you/anyone trying to harm you?
- Disturbed sleep/wake cycle
- psychomotor activity (hypo/hyperactivity)
What does a person with delirium experience?
Inability to interpret stimuli
inability to formulate an effective response to negative stimuli
inability to communicate needs
DDx delirium
Dementia
Depression (41% of those with delirium misdiagnosed with depression)
other psych disorders
CNS pathway
How can you differentiate between delirium and dementia?
delirium:
- rapid onset
- primary deficit is attention
- fluctuates during day
- visual hallucinations common
- cannot attend to MMSE/mini-cog
dementia:
- insidious onset
- primary deficit short term memory
- does not fluctuate
- visual hallucinations less common
- can attend to MMSE, but performs poorly
What should you include in delirium history?
- when did confusion begin
- was there a condition change in past 24 hours?
- any change in sleep pattern?
- any specific thought problems?
- any history of mental illness/cognitive impairment
- any sudden decline or change in physical health or function?
- any new prescriptions/OTC/herbal medications?
What should you include in physical assessment?
VS pulm CV abd (suprapubic, potentially rectal) neuro MMSE Routine and periodic observation (alertness, behavior, mood, affect, verbalizations, motor abilities)
What labs/testing should you potentially include in w/u?
CBC, UA, BMP (electrolytes, BUN, Cr, gluc, albumin)
LFT
TSH
EEG and radiographs
ECG
**don;t need to get all, choose based on H&P
Diagnosing delirium
**hallmark is abnormal MMSE
use CAM, diagnostic of delirium, based on DSM V diagnosis (requires 3/4 features)
How can you prevent delirium?
Recognize risk factors rapid treatment of underlying causes "prehabilitation" --> prevent predisposing factors immunizations early treatment of illness to prevent hospitalization creation of max supportive environment d/c deliriogenic meds/reduce community support systems address stressful situations fam/friends included in early detection mobilization
What is included in supportive environment for delirious patients?
-presence of family, friends
-presence of relative on admission
-items from home
-minimal sensory loss
-manage pain
-night light, minimalize noise
-facilitate nighttime sleep (consolidate activities)
-avoid restraints
-effective communication aimed at reorienting to surroundings
(large, visible clock/cal, board c names of care team members, daily schedule, integration of orienting).
Discuss neuroleptic and sedating med roles in delirium
Should be used as last resort when needed to protect patients from harm (only fearful/paranoid/disturbed/harm potential)
What are guiding principles to pharmacologic treatment of delirium
- useful when behavioral interventions pose safety risk
- when delirium interferes with medical therapies
- when behavior interventions fail
- start low, go slow
What is the first line med treatment?
- low dose neuroleptics
- newer antipsychotics
- careful with EPS
- only use benzo if ETOH withdrawal causing delirium
Discuss haldol dosing
0.5-1mg daily IM, EPS risk
Discuss olanzapine dosing
Zyprexa 2.5-5mg daily, less side effects, better tolerated
Discuss quetiapine dosing
Seroquil 25 mg BID
Discuss lorazepam dosing
ETOH only
- 5-1 mg q 4 hrs IM/IV
- can cause more confusion in older adults
Discuss aftercare for delirium patients
- help pt/family understand experience
- f/u psych care PRN
- instruct to inform health care providers of prior episodes of delirium and suspected etiology
- ask, is it still bothersome to them? (may have PTSD)
Name 4 proposed mechanisms that might explain the onset of delirium
- an insufficiency of cerebral metabolism as demonstrated by diffuse slowing on an EEG in a patient with delirium
- a central abnormality caused by an imbalance of central cholinergic and adrenergic metabolism
- the activation of cytokines
- a stress reaction as evidenced by abnormally high circulating corticosteroid levels and an abnormality in brain network connectivity and changes in inhibitory tone.
What are other meds (besides standard anticholinergics) that are commonly used in elderly pop and may cause anticholinergic effects that lead to delirium?
digoxin
furosemide
prednisone
theophylline
Side effects of neuroepileptics
tardive dyskinesia parkinson's disease dystonia sedation falls osteoporosis hip fractures DM hypotension anticholinergic symtoms cognitive decline increased neurofibrillary tangles QT prolongation stroke MI neuroleptic syndrome (hyperthermia, rigidity) increased mortality
