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ICB > delirium > Flashcards

delirium Flashcards

1
Q

define delirium

A

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

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2
Q

define the earliest stage of delirium

A

Earliest stage = clouding of consciousness, characterised by attentional deficits e.g. vague rambling conversation, drifting off the point, undue distractibility

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3
Q

causes of delirium

A 
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
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4
Q

hypoxic causes of delirium

A

resp failure, MI, cardiac failure, PE

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5
Q

drugs that cause drug induced delirium

A 
Psychotropic drugs
- Antidepressants
- Antipsychotics
- Benzodiazepines
Antiparkinsonian drugs
Anticholinergic drugs
Opiates
Diuretics
(recreational drug intoxication and withdrawal)
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6
Q

features of CAM and the requirements

A

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

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7
Q

screening and assessment of delirium

A

pt more confused or more withdrawn than usual or CAM greater than 5

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8
Q

high risk factors of delirium

A

patient above 65

AMT score less than 4

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9
Q

AMT scoring system

A

age - 1
DoB - 1
Place - 1
Year - 1

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10
Q

mnemonic of delirium for causes

A 
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)
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11
Q

classification of delirium

A

hyperacitve
hypoactiv
mixed

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12
Q

define hyperactive delirium

A

may present with inappropriate behaviour, hallucinations, or agitation. Restlessness and wandering are common

incorrectly diagnosed as acute psychosis

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13
Q

hypoactive delirium define

A

may present with lethargy, reduced concentration, and appetite. The person may appear quiet or withdrawn

misdiagnosed as depression

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14
Q

predisposing factors of delirium

A

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.

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15
Q

complications of delirium

A
  • 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.
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16
Q

clinical features of delirium

A

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

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17
Q

explanation for Ix

A

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

18
Q

DD for delirium

A

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

19
Q

other management methods

A

encourage walking - 3X a day

normalise sleep-wake cycle - discourage napping an increase bright light in daytime

low stimualtion environemnt

20
Q

management of severe distress or pts risk to themselves

A

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
21
Q

risks of haloperidol

A

increased risk of stroke
transient ischaemic attack
changes in cognition

22
Q

define cognitive impairment

A

disturbance of higher
cortical functions including memory, thinking,
judgement, language, perception and
awareness

23
Q

ICD-10/WHO definition of delirium

A

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

24
Q

what feature differentiates between delirium and other similar conditions

A
  • impairment of consciousness
  • fluctuation of symptoms: worse at night, periods of normality
  • abnormal perception (e.g. illusions and hallucinations)
  • agitation, fear
  • delusions
25
Q

when can delirium be mis diagnosed

A

deaf or blind or dysphasic patients

26
Q

why is identifying delirium important

A

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

27
Q

delirium screening tools

A

Single question in delirium (SQiD)

CAM

4AT

6CIT - orientation, attention and recall

longer tests - MOCA, MMSE, ACE

28
Q

progonosis of delirium

A

recovering is dependent in age

more vulnerable to future episodes

29
Q

when to require urgent CT

A 
fall in GCS 15 - 9
progressive neuro defect
unequal pupil
history of seizures 
history of head injury
30
Q

how do you distract a distress delirium pt

A

speak to family on phone

puzzles

pain management of abby scale

31
Q

hyponatraemia causing drugs

A 
carbamazepine - increase sodium retention so increase water retention
citalopram - SSRI
endapamide
spirinolactone 
omeprazole
bisacodyl - excess sodium loss
32
Q

define acute confusion

A

acute deficit in thinking, short-term memory and orientation in
time/place with reduced awareness

33
Q

how does subdural heamatoma look on CT

A

mixed density on CT

crescent shaped

34
Q

how does old subdural haematoma look on CT

A

as the haematoma ages it becomes less isodense and then in a few weeks hypodense - similar to CSF

35
Q

Mx of subdural haematoma causing confusion

A

urgent referral to neurosurgery

- should be observed for any neuro changes

36
Q

what Ix we do for intracranial haemorrhage

A

CT

37
Q

What things can be done initially to help improve her symptoms of delirium in the meantime?

A
  • family members
  • moderate lighting
  • nursing in a side room
  • radio
38
Q

predispose to urinary retention

A

anticholinergic side effects

prostatic problesm

amitriptyline, oxybutinin and codeine.

oxybutynin

constipation

autonomic neuropathy

39
Q

Describe how you would adapt your history taking/information giving for a patient
with cognitive impairment.

A

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.

40
Q

MMSE includes

A 
orientation
registration
attention and calculation
recall
language
41
Q

predisposing RFs of delirium

A 
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

ICB (30 decks)

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