Delirium Flashcards
What are the hallmarks of delirium?
Acute and fluctuating
Inattention
Altered level of consciousness
Disorganised thinking
What are the negative long term consequences of delirium?
Increased mortality Prolonged hospital stay Increased complications; FVT, HAP, pressure sores Increased cost Long-term disability
Describe dementia: Onset Course Duration Activity Alertness Attention Mood Thinking Perception
Onset: slow and insidious course: progressive, irreversible Duration: months to years Activity: wandering, agitated Alertness: normal Attention: normal Mood: low mood may be present Thinking: word-finding difficulties Perception: usually normal in early stages except lewy body dementia
Describe depression: Onset Course Duration Activity Alertness Attention Mood Thinking Perception
Onset: abrupt with life changes Course: worse morning Duration: at least 2 weeks Activity: withdrawn, apathy Alertness: normal Attention: normal Mood: depressed Thinking: slow, depressive themes Perception: intact but delusions and auditory hallucinations in severe cases
Describe delirium: Onset Course Duration Activity Alertness Attention Mood Thinking Perception
Onset: sudden; hours, days
Course: short, fluctuating, reversible
Duration: hours to less than a month
Activity: agitation, restless (hyperactive) or sleepy and slow in hypoactive
Alertness: fluctuates
Attention: impaired, difficult to converse
Mood: fluctuating emotions
Thinking: disorganised
Perception: distorted; illusions and visual hallucinations, delusions
What is the pathophysiology of delirium?
Direct toxic insult to brain: drugs, hypoxia, stroke, hypoglycaemia, dehydration
Abnormalities within body normal stress pattern
What are precipitating factors for developing delirium?
Hypoxia Biochem abnormalities Dehydration Alcohol excess HAP UTI Environmental Catheters Systemic upset - intercurrent illness CV disease #NOF Constipation Urinary retention Pre-existing dementia
Which drugs are particularly bad for precipitating delirium?
Sedative hypnotics - haloperidol, lorazepam Narcotics - esp opioids Anticholinergic drugs Corticosteroids Polypharmacy
Withdrawal of alcohol
What are the subtypes of delirium?
Hyperactive: agitated, aggressive, wandering
Hypoactive: withdrawn, apathetic, sleepy, coma
What 4 A’s does the 4AT scoring system use?
Alertness: difficult to rouse, hyperactive
AMT4
Attention: please tell me the month of the year in backwards order starting at december
Acute change or fluctuating course: evidence of significant change or fluctuation in alertness, cognition or other mental function (paranoia, hallucinations) arising over the last 2 weeks and still evident in the last 24 hours
What is AMT4?
Age
D.O.B
Place (hospital)
Current year
What score on 4AT indicates delirium?
4 or above
What is the CAM method?
Confusion assessment method
What is required in CAM to diagnose delirium?
Feature 1,2 and either 3 or 4
1: acute onset and fluctuating course
2: inattention
3: disorganised thinking
4: altered level of counsciousness
What acute and severe causes of delirium must be ruled out?
Infection/sepsis
Hypoxia
Hypoglycemia
Medicine intoxication
What should be in place if the patient lacks capacity with no power of attorney?
AWI section 47
What is the TIME framework for delirium?
Think
Investigate
Management
Engage and explore
What is included in the T of TIME?
Think, exclude and treat possible triggers:
NEWs (sepsis 6)
BG
Med history (any new meds/change of dose/any stopped)
Assess for urinary retention
Assess for constipation
What is included in the I of TIME?
Investigate and intervene to correct any underlying causes:
Assess hydration and start fluid balance chart
Bloods (FBC, U&Es, LFT, CRP, Mg)
Infection (skin, chest, urine, CNS) and perform appropriate cultures/imaging
ECG (MI/ACS)
What is included in M of TIME?
Management plan
What is included in E of TIME?
Engage with patient, family and carers
Explain diagnosis
Document diagnosis of delirium
What medication can be given in delirium?
LAST RESORT
Haloperidol 0.5-1.0mg PO or 0.5mg IV
AVOID IN PARKINSON’S OR LEWY BODY DEMENTIA
Lorazepam 0.5-1.0mg PO BUT benzodiazepines can worsen or prolong delirium
What environmental changes can be made to aid with delirium recovery?
Ensure glasses and hearing aids available Provide regular reassurance and orientation Use family/familiar faces Reduce noise and visual overstimulation Consider additional staff Sleep chart Regular mobilisation Reduce stress Adequate nutrition and fluids Avoid bed moves
What are some common successful delirium prevention programmes?
Anaesthesia protocols Assessment of bowel/bladder function Early mobilization Extra nutrition Geriatric consultation Hydration Med review Pain management Sleep enhancement Supplemental O2 if hypoxic
