Delirium Flashcards
What is delirium?
Disturbance in attention and change in cognition
How long does it take for delirium to develop?
Develops over short period of time (hours-days) and tends to fluctuate during the day
How common is delirium?
15-60% of older people experience delirium prior to or during hospital admission = diagnosis missed in up to 70%
What is the mortality associated with delirium?
10-26% in patients admitted with delirium
22-76% in patients who develop delirium in hospital = high death rate in months following discharge
What outcomes is delirium associated with?
Increased mortality, prolonged hospital stay, increased complications, increased cost, long term disability
What are the hallmarks of delirium?
Acute change from baseline function
Impaired attention and altered level of consciousness
Fluctuating course
What are the types of delirium?
30% have hyperactive delirium
50% have hypoactive delirium
20% have mixed type
What type of delirium is associated with worse outcomes?
Hypoactive delirium
How do the types of delirium vary from each other?
Hyper = agitated, aggressive, wandering, easy to diagnose Hypo = withdrawn, apathetic, sleepy/coma, often missed
How accurate is the 4AT tool for diagnosing delirium?
89.7% sensitivity and 84.1% specificity
What are the categories of the 4AT?
Alertness = scored 0 or 4
AMT4 = scored 0-2
Attention = scored 0-2
Acute/fluctuating course = scored 0 or 4
What does the score a patient gets on the 4AT indicate?
Score 1-3 = possible cognitive impairment
Score >= 4 = delirium +/- cognitive impairment
What is assessed under the alertness category of the 4AT?
Includes patients who are markedly drowsy or agitated = observe if asleep and attempt to wake, ask patient name and address
What do you ask a patient about when carrying out the AMT4 part of the 4AT?
Ask them their age, DOB, location and what the current year is
How is a patient’s attention assessed using the 4AT?
Ask the patient to state the months of the years backwards starting from December
How is a patient assessed for an acute/fluctuating course of symptoms using the 4AT?
Presence of acute changes or fluctuation in functioning arising over last fortnight and still evident in last 24 hours
What is needed to diagnose delirium using the Confusion assessment method?
Diagnosis requires presence of features 1,2 and either 3 or 4
What are the features listed under the Confusion assessment method?
1 = acute onset and fluctuating course 2 = inattention 3 = disorganised thinking 4 = altered level of consciousness
How should the environment be changed to help manage a patient with delirium?
Quiet and calm, low night lighting, clearly visible clocks and calendars, familiar people, bed as low as possible
What is the management of patients with delirium?
Identify and reverse all underlying causes
Try and restore normal sleep pattern
Assess for urinary retention and constipation
What investigations are done for delirium?
Start fluid balance chart, ECG, bloods, may do culture if signs of infection
What are some general measures that help when managing patients with delirium?
Approach patient calmly and gently from the front
Maintain daytime wakefulness with activities
Allow patients to mobilise as much as possible
Ensure glasses and hearing aids are working
What are some common components of delirium prevention programmes?
Anaesthesia protocols, assessment of bladder/bowel functions, early mobilisation, extra nutrition, geriatric consultation, hydration, medication review, pain management, sleep enhancement, therapeutic cognitive activities
When can sedation be used on a patient with delirium?
Only when they are a danger to themselves or others = must document reasons for giving sedation
What medication may be used to treat delirium?
1st line = haloperidol
2nd line = benzodiazepines
What are the benefits of haloperidol?
High potency with few anticholinergic side effects and no active metabolites
How is haloperidol prescribed to treat delirium?
Start with low dose = 0.25-0.5mg
Maximum of 5mg can be given in 24 hours
Give orally = avoid IM if at all possible
What patients are unsuitable for treatment with haloperidol?
Avoid in Parkinson’s disease and lewy body dementia
What patients are treated with benzodiazepines?
Alcohol/benzodiazepine withdrawal or seizures
Haloperidol contraindicated
What is the first choice benzodiazepine used to treat delirium?
Lorazepam = shorter acting and fewer active metabolites
May worsen delirium
What are some causes of delirium?
Drugs, electrolyte disturbance, drug withdrawal, infection, reduced sensory input, pain, stroke, subdural haemorrhage, urinary incontinence, constipation, metabolic
How is delirium screened for?
All patients >65 should be screened for delirium on admission to hospital
What is the first line medication for delirium in patients with Parkinson’s disease or lewy body dementia?
Lorazepam 500mcg-1mg oral
