Delirium Flashcards
What re the percentages of delirium in different environments?
Acute Medical Admissions- 10% Post-General Surgery- 15% Acute Stroke- 25% Acute Geriatric medical wards- 30% Post-hip Fracture Surgery- 50% Intensive Therapy Unit- 60% Palliative Care Units- 80%
What is delirium associated with?
Increased mortality- 1yr mortality following an admission with delirium is 40%
Prolonged hospital admission
Higher complication rates
Institutionalisation
x3 increased risk of developing dementia
Delirium may be prevented in up to a third of patients
What are the types of delirium?
Hypoactive- 40%
Hyperactive- 25%
Mixed- 35%
What is hypoactive delirium?
Characterised by apathy, withdrawal, lethargy; reduced motor activity, most common type, but often goes unrecognised and can be mistaken for depression patients have longer hospitals stays and are at higher risk of complications associated with reduced mobility (eg. pressure sores)
What is hyperactive delirium?
Characterised by increased motor activity and associated agitation, hallucinations and challenging behaviours, more likely to be recognised, but patients often get treated inappropriately with sedating drugs
What is mixed delirium?
Patients have a mixed picture when suffering with delirium- this often will fluctuate during the course of a day, sleep-wake disturbance
What is the aetiology of delirium? (I WATCH DEATH)
Infection Withdrawal Acute metabolic Trauma CNS pathology Hypoxia Deficiencies Endocrine Acute vascular Toxin Heavy metal
What are some definitions associated with delirium?
Arousal- magnitude of response to perceived stimuli
Cognition- the mental process of thinking and knowing, including aspects such as awareness, perception, memory, language, reasoning and deciding
Consciousness- alertness plus awareness
Attention- ability to focus the mind and sustain focus, on an environmental stimulus, idea or series of connected ideas
Awareness- self perception or inward sensibility
Alertness- ability to respond to external stimulus
What is the diagnostic criteria for delirium based on DSM-5?
A disturbance of consciousness with reduced ability to focus, sustain or shift attention
A change in cognition that develops over a short period of time that is not better accounted for by a pre-existing, established or evolving dementia
Tendency to fluctuate during the course of the day, with disturbance of the sleep wake cycle
Evidence from the history, examinations or investigations that the delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication
What is disturbance of consciousness?
The key is reduced attention, which is the ability to focus, sustain or shift mental focus- patients demonstrate distractibility, drowsiness or reduced vigilance, attention is an unfamiliar and difficult aspect to test – mostly observed during interview
What are other associated features of delirium?
Delusions- often paranoid, tend to be fleeting and lack any system or logic
Emotional changes- anxiety, fear or depression
Motor changes- slowness, restlessness or agitation
Hallucinations- often formed and animated
Cognitive deficits
What are the cognitive deficits associated with delirium?
Language difficulties- word finding difficult
Speech disturbances- slurred, mumbling, incoherent or disorganised
Memory dysfunction- marked short-term memory impairment, disorientation to PPT
Perceptions misinterpretations, illusions, delusions and/or visual or auditory hallucinations
Constructional disability- cannot copy a cube
What are the clinical characteristics of delirium?
Develops acutely- hrs to days
Characterised by fluctuating level of consciousness
Reduced ability to maintain attention
Agitation or hyper-somnolence
Extreme emotional lability- crying/laughing
Cognitive deficits can occur
AMT < 8 out of 10
Which investigations are required for delirium?
Conscious level- use GCS or AVPU
Cognitive function- use Abbreviated Mental Test (AMT) or MMSE a score of <8 is abnormal on AMT
Infection screen- examine for potential source of infection
Nutrition and hydration- assess status
Constipation- rule out urinary retention and perform an abdominal exam and DRE consider post-void bladder scan
Neurology- perform a neurological examination including speech
What does confusion assessment method (CAM) involve?
Acute onset, fluctuating course
Inattention
Disorganised thinking- includes slurred speech
Altered level of consciousness
What are altered levels of consciousness?
Alert- normal Vigilant- hyperalert Lethargic- drowsy, easily aroused Stupor- difficult to arouse Coma- unarousable
What are predisposing risk factors for delirium?
Dementia or Cognitive impairment Physical frailty Multiple co-morbidities Older age->65yrs Sensory impairment- eg. Vision Aged >65yrs Current hip fracture Severe illness Polypharmacy Malnutrition Alcohol excess
What are precipitation risk factors?
Drug initiation/withdrawal Acute brain disease Systemic infection UTI Hyponatreamia Hypoxaemia Shock Surgery Metabolic abnormalities Anaemia Pain Orthopaedic or cardiac surgery ICU admission High number of hospital procedures
What is involved in the prevention of delirium?
Keep orientated and promote the familiar
Facilitate vision and hearing- glasses, light, hearing aid
Keep hydrated and well fed
Reduce medication, avoid anti-cholinergic drugs and opiates
Keep mobile and active
Promote night time sleep
Minimise provocation- noise, tubes and restraints
What are 1st line investigations for delirium?
FBC TFT LFT U&E Glucose CRP ECG Urinalysis CXR
What are 2nd line investigations for delirium?
Lumbar puncture CT head EEG MRI head Specific cultures ABG Calcium, B12, folate Toxicology screen Bladder scan
What are the 4 main elements of the management of delirium?
Identify and treat the underlying cause
Removal of offending medications
Treatment of infection
Correction of hypoxia and metabolic derangement
What is the management for the symptoms of delirium?
Nurse in an optimal environment- quiet, light, appropriate numbers of staff, orientation cues, open bays are not ideal but there needs to be a trade-off taking into consideration the need for observation and patient safety
Promote orientation- clocks, orientation boards, mealtimes
Analgesia as required but avoid opiates if possible
Maintain hydration and nutrition
Good sleep hygiene i.e. avoid sleep during the day, avoid stimulants and too much fluid before bed
Regular clinical updates with relatives and encourage them to be in attendance
Consider 1 to 1 nursing care
Use the least restrictive option with wandering patients
Avoid agreeing with rambling speech by tactfully disagreeing, changing the subject while acknowledging feelings but ignoring content
Keep the use of sedative drugs to a minimum
When are sedative drugs used?
For rapid tranquilisation of an agitated patient when there is an immediate risk of harm or danger
Short term control of distress- only use one drug and start at the lowest dose possible considering increasing increments after 2hrs Haloperidol IV or Lorazepam
Should be kept to a minimum can precipitate
Haloperidol 0.5mg BD- unless patient has Parkinson’s Disease or Lewy Body Dementia
Olanzepine may also be used
Lorazepam may be used for rapid tranquilisation
What is the recovery from delirium?
40% persist at 2 weeks
33% at 1 month
25% at 3 months
20% never recover
What should be included int he history?
- Onset and course of the confusion
- Symptoms of an underlying cause, e.g. symptoms of UTI, constipation, general infection etc.
- Co-morbidities
- Previous episodes of confusion
- Previous forgetfulness / confusion and how this occurred before
- Drug history
- Alcohol history
- Sensory deficits
- Functional status
- Social circumstances including family and support as well as living arrangements
