delirium Flashcards
define delirium
Delirium has an acute onset, fluctuating syndrome of disturbed consciousness, attention, cognition and perception
acute onset confusion with hallucinations or illusions
Continuum from full alertness through to unconsciousness
define the earliest stage of delirium
Earliest stage = clouding of consciousness, characterised by attentional deficits e.g. vague rambling conversation, drifting off the point, undue distractibility
causes of delirium
1) infection - pneumonia UTIs encephalitis meningitis 2) medications 3) drug withdrawal
Drugs (withdrawal/toxicity/anticholinergics)/dehydration
Electrolyte imbalance
Level of pain
Infection/inflammation (post surgery)
Respiratory failure (hypoxia/hypercapnia)
Impaction of faeces
Urinary retention
Metabolic disorder (liver/renal failure, hypoglycaemia)/MI
V- SOL raised ICP head trauma epilepsy I T A M- low sodium hypoglycaemia I Nutritional - low thiamine nicotinic acid Vit B12
Abdominal - Faecal impaction, malnutrition
urinary retention
bladder cauterisation
Endocrine - hyperthyroidism hypothyroidism hypoglycaemia hyperglycaemia cushings
hypoxic causes of delirium
resp failure, MI, cardiac failure, PE
drugs that cause drug induced delirium
Psychotropic drugs - Antidepressants - Antipsychotics - Benzodiazepines Antiparkinsonian drugs Anticholinergic drugs Opiates Diuretics (recreational drug intoxication and withdrawal)
features of CAM and the requirements
feature 1 - acute onset and fluctuating course - 2 points
feature 2 - inattention - 2 points
feature 3 - disorganised thinking - 1 point
feature 4 - altered level of consciousness - 1 point
diagnosis of delirium requires 1 and 2 and 3 or 4
more than 5 or more points
screening and assessment of delirium
pt more confused or more withdrawn than usual or CAM greater than 5
high risk factors of delirium
patient above 65
AMT score less than 4
AMT scoring system
age - 1
DoB - 1
Place - 1
Year - 1
mnemonic of delirium for causes
TRAUMA - head injury intracranial HYPOXIA - pneumonia, PE, CCF, MI, COPD INCREASING AGE/FRAILTY NOF FRACTURE smoKer DRUGS ENVIRONMENT - esp ward moving LACK OF SLEEP, reversal of sleep-wake cycle IMBALANCED ELECTROLYTES - renal failure, Na, Ca, glucose, liver function RETENTION - urinary or constipation INFECTION, SEPSIS UNCOTNROLLED PAIN MEDICAL/MENTAL ( dementia, parkinsons)
classification of delirium
hyperacitve
hypoactiv
mixed
define hyperactive delirium
may present with inappropriate behaviour, hallucinations, or agitation. Restlessness and wandering are common
incorrectly diagnosed as acute psychosis
hypoactive delirium define
may present with lethargy, reduced concentration, and appetite. The person may appear quiet or withdrawn
misdiagnosed as depression
predisposing factors of delirium
alcohol excess
codeine
constipation
malnutrition
sepsis
Older age (over 65 years).
existing cognitive impairment (such as dementia).
Frailty/multiple comorbidities (such as stroke or heart failure).
alcohol excess
Significant injuries such as hip fracture.
Functional impairment (for example immobility or the use of physical restraints such as cot sides).
Iatrogenic events (such as bladder catheterisation, polypharmacy, or surgery).
acute illness or infection
surgery
pain
History of, or current, alcohol excess.
Sensory impairment (such as visual impairment or hearing loss).
Poor nutrition.
Lack of stimulation.
Terminal phase of illness.
complications of delirium
- increased mortality
- Increased length of stay in hospital.
- Nosocomial infections.
- Increased risk of admission to long-term care or re-admission to hospital.
- Increased incidence of dementia.
- Falls.
- Pressure sores.
- Continence problems.
- Malnutrition.
- Functional impairment.
- Distress for the person, their family, and/or carers.
clinical features of delirium
acute confusion state associated with marked fluctuations in orientation and conscious level, including periods of lucidity. Patients are often restless and distressed, with an inability to concentrate.
2) fluctuates behaviour change (hours to days)
- worst at night - ‘sundowning’
2) altered levels of consciousness - hypoactive, hyperactive or mixed - distractable, reduced focus
3) cognitive decline
4) inattention the person may have disorganised, rambling, or irrelevant conversation - the person may be disoriented, have memory and language impairment, worsened concentration, slow responses, and confusion.
- behavioural and psychological disturbances
ABOVE THREE KEY FEATURES
Disorganised thinking —
Altered perception — the person may experience paranoid delusions, misperceptions or, visual or auditory hallucinations
Emotional disturbance
disturbance of the sleep wake cycle
Altered level of consciousness
falling and loss of appetite
explanation for Ix
urinalysis - UTI or hyperglycaemia
sputum culture - chest infection
blood culture - infection
FBC- infection or anaemia
folate and B12 - deficiency
U&Es - AKI, hyponatraemia, hypokalaemia
TFTs - hypothyroidism
LFTs- hepatic failure
ESR, CRP
Drugs
CT - rule out potential acute intracranial changes
chest xray - consolidation
AXR - constipation or obstruction
ECG
DD for delirium
depression - mood change, anorexia, sleep disturbance
dementia - lewy-body - no fluctuations in mental state
mental illness - MANIA late-onset mania or schizo can present similaryly to hyperactive delirium
anxiety
thyroid - hyper/hypo
non-convulsive epilepsy or tempoal lobe epilepsy
charles bonnet syndrome
other management methods
encourage walking - 3X a day
normalise sleep-wake cycle - discourage napping an increase bright light in daytime
low stimualtion environemnt
management of severe distress or pts risk to themselves
FIRST LINE
haloperidol IF CI ie. parkinsons, LBD or prolonged QT interval, antipsychotics
low dose lorazepam
titrate it slowly as there is a risk of respiratory depression
second line short term (1 week or less) - low-dose haloperidol - 0.5-1mg max 2mg in 24 hours
risks of haloperidol
increased risk of stroke
transient ischaemic attack
changes in cognition
define cognitive impairment
disturbance of higher
cortical functions including memory, thinking,
judgement, language, perception and
awareness
ICD-10/WHO definition of delirium
Impairment of cognition; disturbances of attention
and conscious level; abnormal psychomotor
behaviour and affect; disturbed sleep-wake cycle
– Onset is usually acute (hours/days)
– All symptoms fluctuate during daytime and are
typically worst at night
– 2 behavioural subtypes:
• Hyperactive – heightened arousal, restlessness, irritability,
wandering, carphologia (picking at clothing)
• Hypoactive – quiet, sleepy, inactive, unmotivated and EASILY
OVERLOOKED
what feature differentiates between delirium and other similar conditions
- impairment of consciousness
- fluctuation of symptoms: worse at night, periods of normality
- abnormal perception (e.g. illusions and hallucinations)
- agitation, fear
- delusions
when can delirium be mis diagnosed
deaf or blind or dysphasic patients
why is identifying delirium important
increased length stay in hospital
increased mortality rates
increased hospital readmissions
increased chance of needing 24hr care on discharge
higher correlation between ppl who suffer a delirium go onto develop dementia
delirium screening tools
Single question in delirium (SQiD)
CAM
4AT
6CIT - orientation, attention and recall
longer tests - MOCA, MMSE, ACE
progonosis of delirium
recovering is dependent in age
more vulnerable to future episodes
when to require urgent CT
fall in GCS 15 - 9 progressive neuro defect unequal pupil history of seizures history of head injury
how do you distract a distress delirium pt
speak to family on phone
puzzles
pain management of abby scale
hyponatraemia causing drugs
carbamazepine - increase sodium retention so increase water retention citalopram - SSRI endapamide spirinolactone omeprazole bisacodyl - excess sodium loss
define acute confusion
acute deficit in thinking, short-term memory and orientation in
time/place with reduced awareness
how does subdural heamatoma look on CT
mixed density on CT
crescent shaped
how does old subdural haematoma look on CT
as the haematoma ages it becomes less isodense and then in a few weeks hypodense - similar to CSF
Mx of subdural haematoma causing confusion
urgent referral to neurosurgery
- should be observed for any neuro changes
what Ix we do for intracranial haemorrhage
CT
What things can be done initially to help improve her symptoms of delirium in the meantime?
- family members
- moderate lighting
- nursing in a side room
- radio
predispose to urinary retention
anticholinergic side effects
prostatic problesm
amitriptyline, oxybutinin and codeine.
oxybutynin
constipation
autonomic neuropathy
Describe how you would adapt your history taking/information giving for a patient
with cognitive impairment.
Include the family and friends in the communication
Speak in a plain way, using words that are simple. For example, instead of asking if
the person is hungry, ask, “Would you like to eat some eggs?”
Reduce distractions.
Make sure that the person can see you. Turn on the lights if the room is too dark.
Discuss one thing at a time.
Draw pictures or write things down for the person if this helps them understand
what you are trying to say.
Ask one question at a time and listen to or observe for the answer.
Ask closed questions.
Use real objects.
Speak slowly and in a clear way.
Talk with a low pitch, not with a high pitched voice.
Face the person that you are talking to.
Make eye contact with the person.
MMSE includes
orientation registration attention and calculation recall language
predisposing RFs of delirium
Predisposing factors Age > 65 years Male Background cognitive impairment/prior episode of delirium Visual or hearing impairment Poor nutritional status Dehydration Multiple co-morbidities Poor functional status Sleep deprivation
