Delirium Flashcards
what is delirium?
- a geriatric emergency
- an acute decline in cognitive functioning
- usually in response to a noxious insult
- fluctuating syndrome of altered attention, awareness, and cognitive disturbances
what are some non-diagnostic terms describing delirium?
- senility
- dementia
- change in mental status
- acute confusional state
- sundowning
- disoriented
what are some adverse outcomes of delirium?
- higher rates of readmission
- higher rates of institutionalization
- higher mortality
what is the physiology of delirium?
- oxygen deprivation
- physiologic stress
- neurotransmitter hypothesis: reduced cholinergic function, increased dopamine
what are some PREDISPOSING factors for developing delirium?
- dementia
- previous episodes of delirium
- functional impairment
- sensory impairment
- major organ system/comorbidity
- depression
- hx TIA/CVA
- ETOH misuse
- older age (>75yo)
what are some PRECIPITATING factors for developing delirium?
- drugs
- polypharmacy
- use of physical restrains
- use of bladder catheter
- electrolyte imbalance
- infection
- surgery
what are the DSM V criteria for diagnosing delirium?
- disturbance in attention and awareness
- acute onset and fluctuating course
- change in cognition
- evidence of underlying medical condition, or from medication or drug withdrawal
what are the 3 clinical subtypes of delirium?
- hyperactive
- hypoactive
- mixed
how does hyperactive delirium present?
increased psychomotor activity, such as rapid speech, irritability, and restlessness
how does hypoactive delirium present?
- lethargy
- slowed speech
- decreased alertness
- apathy
how does mixed delirium present?
shift btwn hyper- and hypoactive states
what are some symptoms to look for when assessing delirium?
- attentional deficits
- disorganized thinking (altered thought content and thought process)
- disturbance of perception (hallucinations, illusions, delusions)
- disturbed sleep-wake cycle
- psychomotor activity (hyper- and hypo-)
what does the person with delirium experience?
- inability to interpret internal and external stimuli
- inability to formulate an effective response to negative stimuli
- inability to communicate needs
what are some differential diagnoses for delirium?
- dementia
- depression (41% misdiagnosed as depression)
- other psychiatric disorders
- CNS pathology
what are some ways to differentiate delirium from other causes of confusion?
- clinical history
- physical examination
- lab studies
- engaging IDT
what is the difference in onset between delirium and dementia?
- delirium: rapid onset
- dementia: insidious onset
what is the difference in primary deficit between delirium and dementia?
- delirium: primary deficit in attention
- dementia: primary deficit in short term memory
what is the difference in fluctuation of disease course between delirium and dementia?
- delirium: fluctuates during the day
- dementia: does not fluctuate during the day
what is the difference in commonality of visual hallucinations between delirium and dementia?
- delirium: visual hallucinations common
- dementia: visual hallucinations less common
what is the difference in performance on the MMSE between delirium and dementia?
- delirium: cannot attend to MMSE
- dementia: can attend to MMSE, but do poorly
how do you recognize delirium superimposed on dementia?
difficult to recognize
sx not consistent w/ dementia:
- acuteness
- fluctuation
- inattention
- altered LOC
what are some assessment questions to ask when assessing for delirium?
question family members and caretakers…
- when it began
- does the condition change throughout the day
- change in sleep patterns
- thought problems
- hx mental illness/cognitive impairment
- sudden decline/change in physical health/function
- new Rx or OTC meds
what are some critical PE components to rule out or identify causes?
- VS
- pulmonary
- cardiac
- GI (including suprapubic and rectal)
- neurologic
- Mental status exam
what are some specific factors to assess for in psych/neuro exams?
- alertness (alert, hyperalert, hypoalert)
- behavior
- mood
- affect
- verbalizations
- motor abilities
what are some potential lab studies to collect based on history and physical?
- CBC
- UA
- electrolytes
- BUN, creatine
- glucose
- albumin
- LFTs
- TSH
- ECG + radiographs
- EEG
what is the hallmark diagnostic evaluation of delirium?
abnormal mental status exam
what mental status exam is most commonly used to diagnose delirium?
confusion assessment method (CAM)
what are some benefits of using CAM to assess for an diagnose delirium?
- quick and accurate
- based on DSM criteria
- basedo n observations of cardinal elements of delirium, i.e. acute onset/fluctuating course AND inattention; altered LOC OR disorganized thinking
how is the CAM scored?
positive for delirium if 3/4 features present
what are some ways to prevent delirium?
sound geriatric care
- recognize risk factors
- rapid tx of underlying causes
- “prehabilitation”
- immunizations for influenza and pneumococcal PNA
- early tx of illness to prevent hospitalization
- creation of a maximum supportive environment
- deliriogenic meds d/c’d or reduced
- community support systems
- address stressful situations
- family/friends help detect delirium in early stages
what are some ways to promote a supportive environment for those at risk for delirium?
- presence/ability to contact family members, friends, or others PRN
- presence of a relative on admission
- familiar items from home
- minimize sensory losses that contribute to misperceptions
- pain mgmt
- night-light; minimal noise
- facilitate nighttime sleep by consolidating tx, rescheduling meds, and unit-wide noise reduction strategies
what are some additional non-pharm strategies for preventing delirium?
- avoid or minimize physical restraints
- effective communication aimed at reorienting the patient to surroundings
~large, easily visible clock wand calendar
~board w/ names of care team members
~daily schedule
~integration of orienting cues into pt’s daily routine
when should pharmacological interventions be used?
- when behaviors associated w/ psychotic thinking and perceptual disturbances (i.e. hallucinations) pose a safety risk
- when delirium interferes with needed medical therapies
- when behavioral interventions fail
what are some cautions with pharmacologic interventions for delirium?
- meds shouldn’t be substituted for detection, correction, or elimination of the underlying cause or causes of delirium
- sensitivities to anticholinergic side effects of antipsychotic drugs may worsen delirium
- low doses over shortest possible time period
what is first line pharmacologic therapy for delirium?
low doses of neuroleptics
which neuroleptics may be better tolerated in older patients?
newer antipsychotics like olanzapine and quetiapine, rather than typical antipsychotics
what are the most common side effects of antipsychotic medications?
extrapyramidal symptoms (EPS)
- dystonic rxns
- akathisia
- tardive dyskinesia
what medications are recommended with ETOH withdrawal?
benzodiazepines - in non-ETOH withdrawal, benzos may worsen delirium
what are the 3 main medications given to those with delirium (and dosages)? what SEs should we consider?
haldol:
- 0.5-1mg daily, may also use IM
- watch EPS
olanzapine/quetiapine:
- 2.5-5mg daily (zyprexa) or 25mg BID (seroquel)
- fewer SEs
- better tolerated
lorazepam
- 0.5-1mg q4hr; may use IM or IV
- can cause more confusion in older adults
- good for ETOH withdrawal
what is some delirium aftercare we can perform?
- help pt and family understand the experience
- f/u psych care PRN
- instruct pt and family to inform health care providers or prior episodes of delirium and suspected etiology
