Delirium Flashcards
Define delirium
A disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a pre-existing or evolving dementia
DSM-V criteria for delirium
- Attention disturbance
- Acute onset (hours-days)
- Additional disturbance in cognition (e.g. language)
- NOT better explained by another neurocog disorder
- H&P or lab evidence that medical condition, substance intoxication or withdrawal, or medication side effect IS the cause
What is hyperactive delirium?
Acutely agitated
- M/C in younger pt.
What is hypoactive delirium?
Quiet withdrawn state consisting of lethargy and decreased activity
- M/C in older pt., ICU pt.
What fraction of older pts. coming to the ER are delirious?
1/3
___-___% of medical patients are delirious?
10-30%
___-___% of surgical patients are delirious?
6-52%
Is delirium more common in post-op cardiac or post-op hip fx pts.?
Post-op hip fx
Is it common for medical staff (MDs, nurses) to miss delirium?
YES
Up to 67% of cases are missed
Delirium is reported in __-__% of ICU admissions
70-87%
Delirium prognosis IN HOSPITAL
- Longer LOS
- Greater mortality
- Functional disability
Delirium prognosis POST D/C
- More institutionalization
- Persistence of cog sx (high mortality)
- Higher 2 yr mortality
Costs ↑ as severity of delirium
↑
RF for delirium
- Age (>70)
- Dementia
- Functional ADL impairments
- High medical co-morbidity
- ETOH abuse or h/o
- Male
- Sensory impairment
Pathophysiology of delirium
- Cholinergic inhibition
- GABA activation (BZDs)
- Serotonin deficiency
- Cytokine, chemokine
- Dopamine activation
- Cortisol excess
Precipitating factors for delirium:
- Acute cardiac, pulmonary events
- Bed rest
- Sedative or ETOH withdrawal
- Fluid/lyte abnl
- Infections
- Intracranial events
- Meds
- Anemia
- Uncontrolled pain
- Urinary retention, fecal impaction
- Indwelling devices
- Restraints
Life-threatening causes of delirium (WHHHHIMPS)
- Wernicke’s disease
- Hypoxia
- Hypoglycemia
- Hypertensive encephalopathy
- Hyper or hypothermia
- Intracerebral hemorrhage
- Meningitis/encephalitis
- Poisoning (exogenous/iatrogenic)
- Status epilepticus
Conditions associated with delirium (I WATCH DEATH)
- Infections
- Withdrawal
- Acute metabolic
- Trauma
- CNS pathology
- Hypoxia
- Deficiencies
- Endocrinopathies
- Acute vascular
- Toxins/drugs
- Heavy metals
Why does delirium increase with age?
- MORE CNS disease
- LESS CNS reserve
- Age and disease related cardiac, pulmonary, renal, hepatic dysfunction (sensory diminution, psych stress, polypharmacy)
Drugs associated with delirium
- Anticholinergics
- APs
- ADs
- Anxiolytics
- Cardiac drugs
- H2 blockers
- Narcotic analgesics
- Sedative hypnotics
What to investigate FIRST in evaluation of delirious patient:
- Check basic labs (metabolic problems)
- Med review (esp. recent additions)
- Investigate infection (even if not grossly present)
- Assess iatrogenic causes
Ddx for delirous pt.
- Amnestic syndromes
- Dementia
- Ictal or postictal confusion
- MDD
- Paranoid states or psychoses, mania
Focal neurologic mimics of delirium
- Wernicke’s aphasia (impaired comprehension of written & spoken language; inability to speak substantive language)
- Anton’s syndrome (anosognosia; a person who is totally blind but it unaware of their blindness)
- Tumor or trauma in the frontal lobe
- Non-convulsive status epilepticus
Assessing delirium in 3 steps:
- Determine baseline level of function
- Assess level of consciousness
- Formal cognitive assessment
How do we assess level of consciousness?
GCS, RASS
What does GCS assess?
Consciousness NOT agitation
What is RASS
Richmond agitation sedation scale
Why is RASS good for assessing delirium?
Incorporates both sedation & agitation
What are some valid tools for formal cognitive assessment?
CAM, CAM-ICU
What is CAM?
Confusion assessment method
How do we determine baseline level of functioning?
Obtain information from a reliable surrogate
- Do NOT use current hospital status to establish baseline
CAM-ICU is adapted for what kinds of patients?
Pt. on ventilators, nonverbal pts.
Procedure for RASS assessmet
- Observe pt. - level of agitation
- If not alert, state patient’s name and say to open eyes and look at speaker
- When no response to verbal stimulation, physically stimulate pt. by shaking shoulder and/or rubbing sternum
Scoring for RASS assessment - step 1
Combative +4 Very agitated +3 Agitated +2 Restless +1 Alert & calm 0
Scoring for RASS assessment - step 2
Drowsy -1 (pt. awakens w/ sustained eye opening & contact
Light sedation -2 (pt. awakens w/ eye opening & contact, but not sustained)
Moderate sedation -3 (pt. has any movement in response to voice but no contact)
Scoring for RASS assessment - step 3
Deep sedation -4 (pt. has any movement to physical stimulation)
Unarousable -5 (pt. has no response to any stimulation)
If RASS score is -3 through +4
Proceed to step 2
If RASS score is -4 or -5
STOP and reassess pt. at later time
Scoring of CAM
A. Acute onset & fluctuating course
B. Inattention
C. Disorganized thinking
D. Altered level of consciousness
Diagnosis of delirium with CAM requires…..
Both A + B
Either C or D
CAM (A) - Acute onset & fluctuating course
Is there evidence of change from baseline?
Does the abnormal behavior come and go? fluctuate during the day? increase/decrease in severity?
CAM (B) - Inattention
Does the patient have difficulty focusing attention? become easily distracted? have difficulty keep track of what is said?
CAM (C) - Disorganized thinking
Is the patient’s thinking disorganized? incoherent?
Does the patient have rambling speech, unpredictable switching of subjects, flight of ideas?
CAM (D) - Altered level of consciousness
Is the patient….
- Alert
- Vigilant
- Lethargic
- Stuporous
- Comatose
Characteristics of delirium that differentiate it from dementia
- Abrupt onset
- Frequent sx fluctuation
- Impaired consciousness
- Decreased/shifting attention
- Perceptual disturbances
- Hallucinations
- Tremors/asterixis
- Speech is incoherent, disorganized, or manifesting delusions or hallucinations
What are tests you can do to assess inattention?
Digit span test
- Ask pt. to repeat a series of 5 numbers
Say days of the week backwards
Say months of the year backwards
What are the 3 components of management for a delirium pt.?
- Prevention
- Treat underlying disorder
- Manage sx
Which step in delirium management is the most important?
PREVENTION
Prevention can result in a ___% reduction in delirium?
40
What are some things we can do to prevent delirium?
- Repeated orientation of patient
- Cognitive stimulation 3+ times/day
- Non-pharm sleep protocol
- Early mobilization & ROM
- Timely removal catheter, lines, restraints
- Optimize sensory input
- Correct dehydration
- Try environmental/behavioral changes before APs
Managing underlying disorder
- Consider withdrawal form alcohol, BZDs, or opiates
- Review meds
- Infections - identify & treat
- Optimize fluids & lytes
- Correct low perfusion states
- Correct metabolic disorders
Pharmacological mgmt of sx
- Correct physiologic abnl 1st
- APs are agent of choice
What is our AP of choice?
Haloperidol
What drug do we avoid d/t over sedation, exacerbated and prolonged confusional state?
BZDs
What drug don’t we use unless absolutely necessary?
Benadryl
What is our general approach to pharmacologic mgmt
START LOW GO SLOW
What is the black boxed warning ass. w/ APs
Increased risk of death
What “tool” should we avoid in delirious patients that are agitated/combative?
Restraints
