Delirium Flashcards
What is delirium?
An episode of acute, transient and reversible confusion with an acute onset and disturbed attention, consciousness, fluctuant cognition and perception due to an underlying (or multiple) cause. Delirium can be hyperactive or hypoactive.
What are the two types of delirium?
Hyperactive or hypoactive
What are the types of delirium?
1) Hyperactive delirium: Pt experiences agitation, restlessness, aggression, loss of concentration, confusion
- Hallucinations/delusions
- Difficult for carers to manage
2) Hypoactive delirium: Pt experiences slowing down, sleepiness/lethargy, reduction of consciousness and reduced speech or interaction
- Easily missed
- Mis-Ddx: depression or fatigue
- Poor oral intake
- dehydration
- Higher mortality/poor prognosis
3) Mixed: fluctuates rapidly from hypoactive and hyperactive
List 5 differences between dementia and delirium.
Onset: Acute (delirium)
State: Fluctuates (delirium)
Consciousness reduced (delirium)
Perception - hallucinations common (delirium)
Speech - slow/repetitive/incoherent (Delirium)
Reversible
Who develops delirium?
Anyone with a severe enough stimuli
- Vulnerable and frail people ≈ less physiological reserve ≈ require smaller insult
- Common in people with dementia: if sudden worsening, screen for underlying cause
- Very common in ITU
What are the three things required to cause delirium?
- Vulnerable brain
- Risk factors
- Insult
List 5 risk factors for delirium
- Age: > 65
- Background cognitive impairment or dementia
- Surgery: e.g. NOF Fx
- Comorbidities
- Polypharmacy
- Sensory impairment: e.g. peripheral neuropathy
- Functional impairment: e.g. using walking aids or hearing aids
- Sleep disturbance
- Hospital admission
List 3 ways ageing is a risk factor for delirium.
Vascular changes (20% reduction)
Brain volume loss (5% per decade after 40)
Reduced NTs (dopamine reduction 10% per decade in adulthood)
Kidneys (reduced detoxification)
Decreased muscle mass
What is frailty?
Health state related to ageing process in which multiple body systems gradually lose in-built biological reserves
What is the pathophysiology of delirium?
- ∆ to BBB permeability
- Cerebral hemispheres or arousal mechanisms of thalamus + brainstem reticular activating system become impaired; - Cortisol/ stress elevation
- Elevated cytokines / inflammation
- Elevated dopamine
- Reduced acetylcholine transmission
- Elevated serotonin
- Elevated GABA
What is the reticular activating system?
Network in brain stem involved in arousal, sleep, pain and muscle tone whereby ascending fibres arouse and activate the cerebral cortex. The reticular activating system controls the level of consciousness.
How do you identify a patient with delirium?
- Consider in any confused older person
- Don’t assume dementia (collaborative history)
- Plucking of bed clothes and air (carphology + floccillation)
What is carphology?
Plucking at air
What is floccilation?
Plucking at bed clothes
How can you assess Delirium?
History
4AT
Vital Signs
Medication review
Physical + Neurological Examination
Consider capacity
Outline the 4AT test
- Alertness: Ask patient to state name + address
Normal =
0 Mild sleepiness < 10 seconds on waking = 0
Clearly abnormal = 4 - AMT4: Age, DOB, POB, Current Year
No mistakes = 0
1 Mistake = 1
2 or more mistakes = 2
- Attention: Backwards Months Test
7 < correct = 0
Starts but score <7 / refuses to start = 1
Untestable = 2 - Acute change or fluctuating change: Evidence of significant change or fluctuation in: alertness, cognition, other mental function (e.g. paranoia, hallucinations) arising over the last 2 weeks and still evident in the last 24 hours
No = 0
Yes = 4
What are the classifications of precipitating causes of delirium?
Intracranial: infarction/bleed/infection/postictal/medications
Extracranial: infection/metabolic/hypoxia/stress response/anaesthesia and surgery/severe illness/pain
Environment/iatrogenic: emotional distress/sleep deprivation/ change in environment/ sensory impairment/ catheters/ drips/ urinary retention/ constipation
What is the time bundle and when should it be commenced?
4AT = 4 ≤ = initiate TIME bundle within 2 hours
T: Think, exclude and treat triggers
- News
- Blood glucose
- Medication history
- Pain review
- Assess for urinary retention
- Assess for constipation
I: Investigate and intervene
- Assess hydration + start fluid balance chart
- Bloods (FBC, U+E, Ca, LFTs, CRP, Mg, Glucose)
- Look for Sx/Signs of infection
- ECG/CXR/CT-B/LP/EEG
M: Management plan
- Initiate Rx
E: Engage + Explore
- Engage with pt and family
- Explain DDx of delirium to patient
- Document diagnosis of delirium
List 5 medications which could trigger delirium
- Opiates
- Anticholinergics
- Benzodiazepines
- Parkinson drugs
- Anti-psychotics
- Anti-epileptics (anti-convulsants)
- Anti-histamines
- Anti-hypertensives
What should you be weary of regarding UTIs and delirium?
Not all older patients with a positive dip stick will have a UTI, check for symptoms and look for other causes. Asymptomatic bacteriuria is common in older people, affecting 25% women and 10% men over 65.
What is the non-pharmacological management of Delirium?
- Re-orientation strategies + distraction
- Involve families/familiar people
- Use glasses/hearing aids
- Keep mobile/avoid restraints
- Promote sleep with quiet room at night, bright light during the day and dim at night; avoid day time napping
Give two drugs which may be useful int he treatment of delirium.
1) Haloperidol (neuroleptic)
2) Lorazepam (benzodiazepine)
Which of the following is not a plausible way to reduce delirium?
A. Wear glasses
B. Use a hearing aid
C. Sleep
D. Dark rooms
D. Dark rooms
Which of the following is not a plausible way to reduce delirium?
A. Wear glasses
B. Use a hearing aid
C. Hydration
D. Hospitalise in a new environment
D. Hospitalise in a new environment
