Delirium Flashcards
What leads to delirium
Vulnerability + precipitation = delirium
What is delirium
Secondary brain injury
Acute confusional state
What are vulnerabilities that can lead to delirium
Dementia Older Frail Hearing and visual impairment Multi morbidity Polypharmacy
Precipitation that can lead to dementia
Strong painkillers Pain Infection Nutrition Constipation Hydration Medication/ metabolic - hyponatraemia, hypercalcaemia, thyroid Environment Post surgery Catheter Primary events, stroke
Diagnosis of delirium
DSM-V
Disturbance of attention and awareness
Reduce ability to direct focus sustain and shift attention
Reduced orientation to environment
Disturbance develops over a shirt period of time usually hours to a couple of days these changes are from the persons baseline of attention and awareness fluctuates in severity during the course of the day
An additional disturbance in cognition- memory deficit, disorientation, language, visuospatial ability, or perception
Disturbances can not be explained by developing neurocognitive disorder and do not occur in the context of a coma
Evidence for hx exam and lab findings that it is delirium
How to test attention
Count backwards from 20
Go backward through the months
Altered arousal looks like
Sleepiness
Hyper alert
Disordered thinking - how to determine
What’s been going on today
Anything strange been going on
Change in baseline determined by
Talking to relatives
Care home
Pick up telephone
What are the motor features
Hand movements fiddling with bed sheet, piece of paper tearing it up
Carphology
Tilmus
Flocillation
Uncommon but highly specific for delirium
Subtypes of delirium
Hyperactive - wondering, aggressive, agitated, hyper alert, strong, difficult to reason with, pulling out lines Easily recognised often misdiagnosed Less common Hypoactive -quiet, bewildered, sleepy inattentive, tilmus, off legs Higher mortality Unrecognised More common
Screening tools
CAM
4 AT test
SQiD
Management of delirium
Prevent it those that come into hospital and get it whilst here shouldn’t happen
Should have a quiet ward, not sleep deprived, hydrated, prevent immobility, visual and hearing aids are on, spot cog impairment
Recognised
Then treat underlying cause
Conservative- avoiding, tolerating, anticipating, don’t agitate, remove catheter, venflon, avoid pressure sores
Medical- never physically restrain
Unresponsive + haloperidol low dose
Benzos make it worse - better in withdrawal of benzos and alcohol
DO NOT USE HALIPERIDOL IN PD OR LEWY BODY DEMENTIA CAN MAKE THE BRADYKINESIA WORSE
Why is delirium Bad
Inc risk of death
Institutionalisation
Can accelerate dementia in those with dementia
Those without dementia in those without it
Differential diagnosis
Lewy body dementia Acute psychosis Wernickes encephalopathy- need to ensure pabrinex Acute severe depression Hypoglycaemia Brain stem CVA Dementia esp late on in disease Lambic encephalopathy- autoimmune Post ictal state Non convulsive status epilepticus
