Delirium Flashcards
is delirium a syndrome or a disease/disorder
syndrome
DSM-5 for delirium
- disturbance in attention
- develops over short period of time and fluctuates
- change from baseline
- disturbance in cognition
- not better explained by another preexisting disorder (dementia)
- evidence that it is caused by medical condition, substance intoxication or withdrawl, or medication side effect
3 different types of delirium
hyperactive, hypoactive, mixed
most commonly missed type of delirium
hypoactive
how many adults admitted to general medical service get delirious
1/3
who has higher rates of delirium - medical patients or surgical patients
surgical - specifically post-op hip fracture and post-op cardiac patients
percentage of ICU admissions who get delirium
70-80%
delirium prognosis
more institutionalization
persistence of cognitive symptoms
higher 2 year mortality
risk factors/predisposing factors for delirium
- age >70
- dementia
- functional ADL impairments
- high medical co-morbidity
- EtOH abuse or history of
- male
- sensory impairment
precipitating factors for delirium
- acute cardiac events
- acute pulmonary events
- bed rest
- sedative or EtOH withdrawl
- fluid/lyte abnormalities
- **infections
- ** meds
- intracranial events
- anemia
- uncontrolled pain
- urinary retention
- indwelling devices
- restraints
life threatening causes of delirium
Wernicke's Hypoxia Hypoglycemia Hyper or hypo thermia Intracerebral hemorrhage Meningitis/encephalitis Poisoning Status epilepticus
why is delirium more common with increasing age
- more CNS disease and less CNS reserve
- age and disease related cardiac, pulmonary, renal, hepatic dysfunction
drugs associated with delirium
- antipsychotics
- antidepressants
- anticholinergics
- H2 blockers
- cardiac drugs
- sedative hypnotics
- narcotics
what should you be thinking of when someone presents with delirium
- metabolic problems
- medications
- infection
- iatrogenic
focal neurologic mimics of delirium
- temporal-parietal (Wernicke’s)
- occipital (Anton’s syndrome)
- frontal (tumor, trauma)
- non-convulsive status-epilepticus
first 3 steps in assessing delirium
- assess baseline level of function
- determine level of consciousness
- formal cognitive assessment
how to determine baseline level of function
- distinguish pre-existing cognitive dysfunction from delirium
- obtain additional history on baseline level of function from family, friends, PCP
how to assess level of consciousness
RASS (Richmond Agitation Sedation Scale)
GCS (doesn’t factor in agitation)
what to do if RASS is -4 or -5
stop and reassess pt at a later time –> we are watiting for a fluctuation in function
what is the formal cognitive assessment used in delirium
CAM or CAM-ICU (confusion assessment method)
What makes up the CAM score
has to have both: 1) acute onset & fluctuating course; 2) inattention
has to have at least one of: 3) altered level of consciousness; 4) disorganized thinking
how to assess inattention
- digit span test
- say day of week backwards
- say months of year backwards
how to assess disorganized thinking
- rambling speech
- repeating things over and over again
3 main steps for delirium management
- PREVENTION!
- treat underlying disorder
- manage symptoms
steps to prevent delirium
- repeated orientation
- early walking/mobilization
- cognitive stimulation 3x/day
- early removal of catheters, lines, restraints
- optimize sensory input
- correct dehydration
- environmental/behavioral changes before antipsychotics
patient-care program to prevent delirium
Hospital Elder Life Program (HELP)
things to consider when managing the underlying disorder
- EtOH, benzo, opiate withdrawl?
- meds?
- infections?
- fluids/electrolytes?
- hypoxia?
- metabolic disorders
pharmacological symptom management
- correct psychological abnormalities 1st
- antipsychotics - agents of choice
- HALOPERIDOL best data and safest
- start low, go slow!!!**
what drugs should you avoid in management of delirium
- benzos
- Benadryl
