Delirium Flashcards
What two types of surgery is delirium most likely to occur after?
Cardiac and orthopedic surgery
90% of the time in cardiac
What are the diagnostic criteria for delirium?
A. Disturbance in attention and awareness
B. Change in cognition (memory, orientation, language, visuo-spatial ability, perception)
C. Happens over a short period of time and tends to fluctuate in severity during the day
What are the two subtypes of delirium? What uniquely characterizes them?
- Hyperactive - hypervigilant, hyperactive, decreased sleep, appear manic and may have more overt psychosis (looks like PTSD / manic BPAD)
- Hypoactive - “quiet” - slowed, unaware, somnolent, withdrawn, may even look depressed
What features are common to both types of delirium?
Distractibility / irritability, all the changes in the criteria, and hallucinations / paranoia
What happens to the sleep-wake cycle in delirium?
It becomes fragmented, and may undergo reversal (sleeping during the day and awake at night) -> nightmares can even continue as hallucinatory experiences
What is sundowning?
The exacerbation of delirium at bedtime
What happens to affect in delirium?
It is labile
May have euphoria in steroid-induced
Other patients may be very depressed
Does delirium just come on without any warning?
Typically no, there is a prodrome period of anxiety / irritability / sleep disturbance
What does an EEG generally show for delirium? Is it generally ordered?
Moderate to severe background slowing
Rarely ordered
What is etiology of most delirium? Give top two.
Most common single causes:
- Medication-induced
- Infection-induced
Almost half are multifactorial though, and environmental stressors contribute to symptoms / severity
What types of illnesses commonly cause delirium?
CNS illnesses: i.e. infection, tumor, stroke, autoimmune
Systemic illness: any organ system, especially UTIs -> sepsis
How can medications induce delirium? What types of medications most often do?
Often intoxication or withdrawal from a drug can precipitate it
Most often polypharmacy, especially with benzodiazepines, anticholinergic burden, and opiates
What are two neurotransmitters are involved in delirium?
- Acetylcholine - decreased (like Alzheimer’s)
2. Dopamine - increased (like Schizophrenia)
How does albumin level affect one’s risk for delirium?
Lower levels = higher risk -> less binding of drugs and increased free serum drug levels
Can delirium have longterm consequences?
Yes -> permanent cognitive deficits can result, as well as reduced patient outcomes (length of stay, death, post-surgical complications). Also associated with poor functional recovery in elderly and increased risk of cognitive decline.
What is the course of delirium / how long does it take to resolve?
Persist until underlying cause is corrected
Recovery period is greater the older the patient, and may persist for up to 6 months after the causative factor is removed
How can delirium be prevented?
- Hydrate well
- Limit use of physical restraints - cause confusion
- Avoid indwelling catheters (cause the UTI / sepsis)
- Correct sleep deprivation
- Avoid problem drugs
What are some re-orientation techniques which can be used to make the room more familiar to the patient?
Put clocks, a calendar, family photos, and some light at night. Try not to change medical staff often.
What sensory considerations should be made to treat delirium?
- Reduce noise - give earplugs to wear at night
2. Correct sensory deficits to help re-orient them (make sure they have glasses / hearing aids)
How are antipsychotics used in the treatment of delirium? What should be done to limit adverse effects?
Used in low doses on a short term basis when there is agitation (hyperactivity) threatening safety
Give an EKG at baseline to check for QT prolongation
What is the main antipsychotic used in treatment of delirium and its side effects? Give one alternative drug.
Haloperidol
QT prolongation and electrolyte disturbance
(among other EPS side effects / NMS)
Alternative: Risperidone
What is the only time benzodiazepines should be used in the treatment of delirium?
Delirium secondary to benzodiazepine / alcohol withdrawal
