Delirium Flashcards
What are the usual presenting features of delirium?
Acute onset fluctuating course inattention disorganised thoughts altered conscious level
Delirium in a patient can have more than one cause. TRUE/FALSE?
TRUE
e.g. direct impact from their medical condition, and issues from their medication
What negative consequences does delirium have both for the patient and for the hospital?
- Increased mortality risk
- Prolonged hospital stay (=> complications and cost)
- Long-term disability
What complications may patients experience if they have to stay in hospital for a prolonged period due to their delirium?
Hospital acquired pneumonia
Bed “pressure” sores
How should the families of delirious patients be reassured?
- Keep them informed of the plans for their relative
- Make them aware that delirium is often caused by precipitants which are treatable
What makes Dementia different from delirium?
Dementia
- more insidious onset
- progressive memory loss, not reversible
- Pts often wander and become agitated
- Usually pts with dementia are alert and pay attention
How does depression differ from Delirium?
Depression:
- worse in morning
- patients are withdrawn/ apathetic
- low mood
- normal alertness
- relatively normal attention
The pathophysiology of delirium is not widely understood. What two theories have been considered as causes?
Direct toxic insults to the brain
e.g. Drugs, hypoxia
Abnormal stress response from the body (metabolic)
e.g. Cortisol, prostaglandins
What factors can predispose patients to developing delirium?
- Elderly
- Dementia
- Depression
- Co-morbidities
- Post-operative period
- Sensory impairment
- Polypharmacy
- Alcohol dependency
- Malnutrition
What are the main precipitants of delirium?
- Infection
- dehydration
- hypoxia
- medication
- alcohol
- constipation
When a patient is described as “disorientated in TPP” what does this mean?
The patient is disorientated in Time, Place, Person
=> cannot recall who or where they are
What structures are used during taking a history to assess for delirium?
Confusion Assessment Method (CAM)
4AT (4As Tool)
What types of delirium exist and which is most common?
50% HYPOactive
20% HYPERactive
30% mixed
Why is HYPOactive delirium more dangerous than hyperactive?
It often goes unnoticed/ undiagnosed as patients are drowsy and aren’t thought to be delirious
Describe the difference in symptoms of HYPER and HYPOactive delirium?
HYPER - Agitated, aggressive, wandering
HYPO - Withdrawn, apathetic, sleepy, coma
What are the components of the 4AT and what score indicates delirium?
Alertness
AMT4 (name, DOB, place, year)
Attention
Acute change/fluctuation
A score of 4/12 = delirium
Describe the CAM process and how delirium is suspected/diagnosed?
Must have both:
1 - Acute onset and fluctuating course
2 - Inattention
AND EITHER OF:
3 - Disorganised thinking
4 - Altered consciousness
What environmental changes can be made in hospital setting to help delirious patients feel more comfortable?
- Same staff visiting them
- Quiet/calm environment
- Low night lighting
- Clearly visible clocks and calendars
- Bed as low as possible
- Don’t routinely use bed rails
How can the family help to manage patients with delirium?
Keep them informed (leaflets etc)
Allow them to visit when patient is agitated as a familiar face may calm them down
What legislation should be considered if the patients do not have capacity to agree to their management?
Mental Health Act
“Adults with Incapacity” section 47
A power of attorney or guardian should be involved in management decisions if possible
What is involved in the Think Delirium Time Bundle?
T - Triggers (sepsis, medication, constipation etc)
I - Investigations (assess hydration, bloods, infection)
M - Management
E - Engage and Explain to family (and document delirium diagnosis)
Medication can NOT be given to treat delirium. TRUE/FALSE?
FALSE
Medication shouldn’t be given unless a last resort, and the patient is either a harm to themself or others
A lady with suspected delirium is admitted on these medications:
aspirin, simvastatin, bendroflumethiazide, co-codamol 30/500, citalopram, levothyroxine and tolterodine.
Which of these could be contributing to her delirium?
Tolterodine = anticholinergic (known to cause delirium)
co-codamol = opiate (can cause delirium)
levothyroxine = are her thyroid function tests okay? if not a metabolic abnormality could cause delirium
Patients who experience rehabilitation before an operation are less likely to experience delirium post op. TRUE/FALSE?
TRUE
In what conditions should Haloperidol be avoided?
Parkinsons
Lewy Body Dementia
When should benzodiazepines be used?
- in alcohol or benzodiazepine withdrawal
- in seizures
- If contraindications to haloperidol
Benzodiazepines can worsen delirium. TRUE/FALSE?
TRUE
lorazepam can worsen delirium
