Delirium Flashcards
What are the causes of delirium?
- Infection = UTI, chest, skin - wounds, cannulas
- Brain = RICP (bleed, space occupying lesion), stroke, meningitis, alcohol withdrawal
- Resp = CO2 retention, pneumonia, hypoxia
- Cardiac = MI, HR
- Bowel = obstruction, vit B, folate def, dont open bowel 3-4 days - do PR exam
- Iatrogenic = drugs (opiates, anticonvulsants, levodopa, sedatives)
- Liver = failure, uraemia
- Urinary = retention
- Vessels = low Hb, hyponatraemia, hypoglycaemia
- Arthritis = pain
- Sleep = lack off
What is delirium?
Any fluctuating baffling behavioural change from the baseline
Impairment of cognition, disturbances of attention and conscious level, abnormal psychomotor disturbance
Disturbed sleep wake cycle
What are the signs and symptoms of delirium?
◦ D = diff in understanding - drowsy, sleepy, lethargic, diff to arose
◦ E = eating/drinking changes
◦ L = language change
◦ I = illusions and hallucinations - fragmentary and transient
◦ R = reversal of sleep/wake cycle
◦ I = inattention
◦ U = unaware of whats going on around them
◦ M = memory impairment (AMTS - assess memory, establish baseline)
Outline the different subtypes of delirium
Hypoactive
- psychomotor retardation
- lethargy
- quiet
- paucity of speech
Hyperactive
- oversensitive to stimuli
- psychomotor agitation
- hallucinations
- aggression
- hyperaroused
- restlessness
Mixed
How should delirium be investigated?
- Bloods = FBC, CRP, U+Es, LFTs, glucose, vit B, folate
- Bedside = temp, BM, ECG
- ABG - acid base balance, hypoxia
- CT/MRI head - lesion, RICP (focal neurology can develop later)
- CXR - infection
- AXR - obstruction
- PR - constipation
- Urine dip - infection
- MSU if >65 - infection
- Bladder scan - retention
- LP - meningitis (make sure no RICP first)
- Sepsis screen
How should delirium be managed?
• Reduce distress (make sure glasses/hearing aid uses have them)
• Nurse in moderately lit room
• Minimise medications
• Treat the cause
◦ Sepsis = 6, IV merpenem
◦ Constipation = laxatives, enema (always query obstruction)
◦ Urinary retention = catheter, TWOC asap
◦ MI
◦T2RF = NIV (must perform CXR before and after - ?pneumothorax)
◦ Infection = Abx
What tools can be used to asses and diagnose delirium?
CAM = confusion assessment method (must have 1+2 and either 3 or 4)
- 1: acute, fluctuating
- 2: inattention
- 3: disorganised thinking
- 4: altered level of consciousness
4AT = 4 a’s test (later, attention, AMT4, acute/fluctuating)
6CIT = Six Item Cognitive Impairment Test
Outline how to discriminate between delirium and dementia
Delirium = occurs abruptly, inattention or distraction, usually reversible
Dementia = insidious onset
Which subtype of delirium is most overlooked?
Hypoactive delirium
Mistaken for depression
Which subtype of delirium is most common?
Hypoactive
Mistaken for depression
What is diagnostic overshadowing?
Diagnostic overshadowing is the attribution of a person’s symptoms to their mental condition, when such symptoms actually suggest a comorbid condition.
What are the risk factors of delirium
Age over 65 Infection Fracture on admission Multiple co-morbidities Underlying dementia Renal impairment Male gender Sensory impairment (hearing or visual) Medication
What medications are risk factors for delirium?
Antidepressants Antipsychotics Benzodiazepines Antiparkinsons Anticholinergics Opiates Diuretics Recreational drug intoxication and withdrawal
What are the screening tools for delirium?
CAM - you need 1 and 2 and either 3 or 4 to diagnose delirium
Score >5
AMT - Score <4
What are the potential underlying causes of delirium?
Hypoxia (post-operatively)
Infection (commonly UTI or LRTI)
Drug-induced (benzodiazepines, diuretics, opioids, or steroids) or drug withdrawal (alcohol or BZNs)
Dehydration or pain
Constipation or urinary retention
Endocrine abnormalities (e.g. hyponatraemia, hypernatraemia, or hypercalcaemia)
