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Geriatrics 2 > Delirium > Flashcards

Delirium Flashcards

1
Q

Define delirium

A

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

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2
Q

DSM-V criteria for delirium

A
  • 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
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3
Q

What is hyperactive delirium?

A

Acutely agitated

- M/C in younger pt.

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4
Q

What is hypoactive delirium?

A

Quiet withdrawn state consisting of lethargy and decreased activity
- M/C in older pt., ICU pt.

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5
Q

What fraction of older pts. coming to the ER are delirious?

A

1/3

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6
Q

___-___% of medical patients are delirious?

A

10-30%

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7
Q

___-___% of surgical patients are delirious?

A

6-52%

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8
Q

Is delirium more common in post-op cardiac or post-op hip fx pts.?

A

Post-op hip fx

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9
Q

Is it common for medical staff (MDs, nurses) to miss delirium?

A

YES

Up to 67% of cases are missed

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10
Q

Delirium is reported in __-__% of ICU admissions

A

70-87%

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11
Q

Delirium prognosis IN HOSPITAL

A
  • Longer LOS
  • Greater mortality
  • Functional disability
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12
Q

Delirium prognosis POST D/C

A
  • More institutionalization
  • Persistence of cog sx (high mortality)
  • Higher 2 yr mortality
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13
Q

Costs ↑ as severity of delirium

A

↑

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14
Q

RF for delirium

A
  • Age (>70)
  • Dementia
  • Functional ADL impairments
  • High medical co-morbidity
  • ETOH abuse or h/o
  • Male
  • Sensory impairment
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15
Q

Pathophysiology of delirium

A
  • Cholinergic inhibition
  • GABA activation (BZDs)
  • Serotonin deficiency
  • Cytokine, chemokine
  • Dopamine activation
  • Cortisol excess
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16
Q

Precipitating factors for delirium:

A
  • 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
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17
Q

Life-threatening causes of delirium (WHHHHIMPS)

A
  • Wernicke’s disease
  • Hypoxia
  • Hypoglycemia
  • Hypertensive encephalopathy
  • Hyper or hypothermia
  • Intracerebral hemorrhage
  • Meningitis/encephalitis
  • Poisoning (exogenous/iatrogenic)
  • Status epilepticus
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18
Q

Conditions associated with delirium (I WATCH DEATH)

A
  • Infections
  • Withdrawal
  • Acute metabolic
  • Trauma
  • CNS pathology
  • Hypoxia
  • Deficiencies
  • Endocrinopathies
  • Acute vascular
  • Toxins/drugs
  • Heavy metals
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19
Q

Why does delirium increase with age?

A
  • MORE CNS disease
  • LESS CNS reserve
  • Age and disease related cardiac, pulmonary, renal, hepatic dysfunction (sensory diminution, psych stress, polypharmacy)
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20
Q

Drugs associated with delirium

A
  • Anticholinergics
  • APs
  • ADs
  • Anxiolytics
  • Cardiac drugs
  • H2 blockers
  • Narcotic analgesics
  • Sedative hypnotics
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21
Q

What to investigate FIRST in evaluation of delirious patient:

A
  1. Check basic labs (metabolic problems)
  2. Med review (esp. recent additions)
  3. Investigate infection (even if not grossly present)
  4. Assess iatrogenic causes
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22
Q

Ddx for delirous pt.

A
  • Amnestic syndromes
  • Dementia
  • Ictal or postictal confusion
  • MDD
  • Paranoid states or psychoses, mania
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23
Q

Focal neurologic mimics of delirium

A
  • 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
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24
Q

Assessing delirium in 3 steps:

A
  1. Determine baseline level of function
  2. Assess level of consciousness
  3. Formal cognitive assessment
25
Q

How do we assess level of consciousness?

A

GCS, RASS

26
Q

What does GCS assess?

A

Consciousness NOT agitation

27
Q

What is RASS

A

Richmond agitation sedation scale

28
Q

Why is RASS good for assessing delirium?

A

Incorporates both sedation & agitation

29
Q

What are some valid tools for formal cognitive assessment?

A

CAM, CAM-ICU

30
Q

What is CAM?

A

Confusion assessment method

31
Q

How do we determine baseline level of functioning?

A

Obtain information from a reliable surrogate

- Do NOT use current hospital status to establish baseline

32
Q

CAM-ICU is adapted for what kinds of patients?

A

Pt. on ventilators, nonverbal pts.

33
Q

Procedure for RASS assessmet

A
  1. Observe pt. - level of agitation
  2. If not alert, state patient’s name and say to open eyes and look at speaker
  3. When no response to verbal stimulation, physically stimulate pt. by shaking shoulder and/or rubbing sternum
34
Q

Scoring for RASS assessment - step 1

A 
Combative +4
Very agitated +3
Agitated +2
Restless +1 
Alert & calm 0
35
Q

Scoring for RASS assessment - step 2

A

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)

36
Q

Scoring for RASS assessment - step 3

A

Deep sedation -4 (pt. has any movement to physical stimulation)
Unarousable -5 (pt. has no response to any stimulation)

37
Q

If RASS score is -3 through +4

A

Proceed to step 2

38
Q

If RASS score is -4 or -5

A

STOP and reassess pt. at later time

39
Q

Scoring of CAM

A

A. Acute onset & fluctuating course
B. Inattention
C. Disorganized thinking
D. Altered level of consciousness

40
Q

Diagnosis of delirium with CAM requires…..

A

Both A + B

Either C or D

41
Q

CAM (A) - Acute onset & fluctuating course

A

Is there evidence of change from baseline?

Does the abnormal behavior come and go? fluctuate during the day? increase/decrease in severity?

42
Q

CAM (B) - Inattention

A

Does the patient have difficulty focusing attention? become easily distracted? have difficulty keep track of what is said?

43
Q

CAM (C) - Disorganized thinking

A

Is the patient’s thinking disorganized? incoherent?

Does the patient have rambling speech, unpredictable switching of subjects, flight of ideas?

44
Q

CAM (D) - Altered level of consciousness

A

Is the patient….

  • Alert
  • Vigilant
  • Lethargic
  • Stuporous
  • Comatose
45
Q

Characteristics of delirium that differentiate it from dementia

A
  • Abrupt onset
  • Frequent sx fluctuation
  • Impaired consciousness
  • Decreased/shifting attention
  • Perceptual disturbances
  • Hallucinations
  • Tremors/asterixis
  • Speech is incoherent, disorganized, or manifesting delusions or hallucinations
46
Q

What are tests you can do to assess inattention?

A

Digit span test
- Ask pt. to repeat a series of 5 numbers
Say days of the week backwards
Say months of the year backwards

47
Q

What are the 3 components of management for a delirium pt.?

A
  1. Prevention
  2. Treat underlying disorder
  3. Manage sx
48
Q

Which step in delirium management is the most important?

A

PREVENTION

49
Q

Prevention can result in a ___% reduction in delirium?

A

40

50
Q

What are some things we can do to prevent delirium?

A
  • 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
51
Q

Managing underlying disorder

A
  • Consider withdrawal form alcohol, BZDs, or opiates
  • Review meds
  • Infections - identify & treat
  • Optimize fluids & lytes
  • Correct low perfusion states
  • Correct metabolic disorders
52
Q

Pharmacological mgmt of sx

A
  • Correct physiologic abnl 1st

- APs are agent of choice

53
Q

What is our AP of choice?

A

Haloperidol

54
Q

What drug do we avoid d/t over sedation, exacerbated and prolonged confusional state?

A

BZDs

55
Q

What drug don’t we use unless absolutely necessary?

A

Benadryl

56
Q

What is our general approach to pharmacologic mgmt

A

START LOW GO SLOW

57
Q

What is the black boxed warning ass. w/ APs

A

Increased risk of death

58
Q

What “tool” should we avoid in delirious patients that are agitated/combative?

A

Restraints

Geriatrics 2 (4 decks)

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