Delirium Flashcards
1
Q
What is the defintion of Delirium?
A
Acute, transient, global organic disorder of CNS functioning resulting in impaired consciousness and attention.
2
Q
What are different types of Delirium?
A
- Hypoactive: presents with lethargy, reduced motor activity. Most common type of delirium and can be confused with depression
- Hyperactive: presents with agitation, irritability, restlessness and aggression. Hallucination and delusions are prominent. May be confused with functional psychoses
- Mixed: both hypo- and hyperactive subtypes co-exist and therefore signs of both
3
Q
What are causes of Delirium?
A
- Hypoxia: respiratory failure, myocardial infarction, cardiac failure, pulmonary embolism
- Endocrine: Hyperthyroidism, Hypothyroidism, Hyperglycaemia, Hypoglycaemia, Cushing’s
- Infection: Pneumonia, UTI, Encephalitis, Meningitis
- Stroke and other intracranial events: Stroke, Raised ICP, Intracranial haemorrhage, Space-occupying lesions, Head trauma, Epilepsy, Intracranial infection
- Nutritional: Reduced thiamine, Reduced nicotinic acid, Reduced Vit B12
- Others: Severe pain, Sensory deprivation, Relocation, Sleep Deprivation
- Theatre: Anaesthetic, Opiate analgesics
- Metabolic: Hypoxia, Electrolyte disturbance, Hypoglycaemia, Hepatic Impairment, Renal Impairment
- Abdominal: Faecal impaction, Malnutrition, Urinary retention, Bladder catheterization
- Alcohol: Intoxication, Withdrawal (delirium tremens)
- Drugs: Benzodiazepine, Opioids, Anticholinergics, Anti-parkinsonian medications, Steroids
4
Q
What are risk factors of Delirium?
A
- Older age (>65)
- Dementia
- Renal impairment
- Sensory impairment
- Recent surgery
- Multiple co-morbidities
- Physical frailty
- Male sex
- Previous episode
- Severe illness
5
Q
What are clinical features of Delirium?
A
- Disordered thinking: Slowed, irrational, incoherent thoughts.
- Euphoric, fearful, depressed or angry.
- Language impaired: Rambling speech, repetitive and disruptive
- Illusions, delusions (transient persecutory or delusions of misidentification) and hallucinations (usually tactile or visual).
- Reversal of sleep-wake pattern: i.e. may be tired during day and hyper-vigilant at night.
- Inattention: Inability to focus, clouding of consciousness.
- Unaware/disoriented: Disoriented to time, place or person.
- Memory deficits
6
Q
What is the ICD-10 Criteria for Delirium?
A
ICD-10 criteria for diagnosis of Delirium
- Impairment of consciousness and attention
- Global disturbance of cognition
- Psychomotor disturbance
- Disturbance of sleep-wake cycle
- Emotional disturbances
7
Q
What is the definition of Dementia?
A
Dementia is a syndrome of generalized decline of memory, intellect and personality without impairment of consciousness leading to functional impairment
8
Q
What are investigations for Delirium?
A
- Routine Investigations: Urinalysis, FBC, U&Es, LFTs, Calcium, Glucose, CRP, TFTs, B12, Folate, Ferritin, ECG, CXE, Blood culture, MSU
- Investigations based on history/examination: ABG, CT head. May consider EEG and lumbar puncture if indicated
- Diagnostic questionnaire: AMT, CAM, MMSE
9
Q
What is the management of Delirium?
A
- Treat underlying causes: treat infections, correct any electrolyte disturbances, stop any offending drugs, laxative for faecal impaction, catheterization for urinary retention, give analgesia if required
- Reassurance and Re-orientation: reassure patient to reduce anxiety and disorientation, regular reminding of time, place, day and date for patients
- Provide appropriate environment: consistency in care and staff; reassuring nursing staff; quiet well-lit side room; encourage presence of friend or family member; optimize sensory acuity
- Managing disturbed, violent or distressed behaviour: encourage oral intake and pay attention to continence; verbal and non-verbal escalation techniques; oral low dose haloperidol or olanzapine; avoid benzodiazepine; referral to care of elderly consultant
10
Q
What are aetiologies of Dementia?
A
Irreversible Causes of Dementia
- Neurodegenerative: Alzheimer’s disease, Fronto-temporal dementia, Picks disease, Dementia with Lewy Bodies, Parkinson’s disease with Dementia, Huntington’s disease
- Infections: HIV, Encephalitis, Syphillis, CJD
- Toxins: Alcohol, Barbiturates, Benzodiazepines
- Vascular: Vascular dementia, Multi-infarct dementia, CVD
- Traumatic Head Injury
Reversible Causes of Dementia
- Neurological: Normal pressure hydrocephalus, Intracranial Tumours, Chronic Subdural haematoma
- Vitamin deficiencies: B12, Folic Acid, Thiamine, Nicotinic acid (pellagra)
- Endocrine: Cushing’s syndrome, Hypothyroidism
11
Q
What are risk factors of Dementia?
A
- Dementia increases with age
- Family history
- Genetics: Presenilin 1 &2, Amyloid precursor protein, and ApoE-4
- Down’s syndrome: T21 are associated with development of pre-senile AD
- Low IQ
- Cerebrovascular disease and Vascular risk factors (overall prevalence is similar to males and female but AD is more common in females and mixed dementia in men)
12
Q
What are ICD-10 Classification of Dementia?
A
ICD-10 Classification of Dementia
- Evidence of the following:
- A decline in memory, which is most evident in the learning of new information, although in more severe cases, the recall of previously learned information may also be affected
- Decline in other cognitive abilities, characterized by deterioration in judgement and thinking, such as planning and organizing, and in the general processing of information.
- Preserved awareness of the environment for a period of time long enough to demonstrate (A).
- A decline in emotional control or motivation, or a change in social behaviour, manifested by one of the following: (1) Emotional lability; (2) Irritability; (3) Apathy; (4) Coarsening of social behaviour.
- For a confident diagnosis (A) must have been present for at least 6 months.
13
Q
What are routine investigations for Dementia?
A
- Blood tests: FBC, CRP, U&Es, Calcium, LFTs, Glucose, Vitamin B12 and Folate, TFTs
14
Q
What are non-routine investigations for dementia?
A
- Urine dipstick: Rule out UTI
- Chest X-ray: pneumonia, lung tumour
- Syphilis serology and HIV testing: only if there are atypical features or special risks
-
Brain imaging: imaging is only indicated for dementia if there is only onset (<60), sudden decline, high risk of structural pathology, focal CNS signs or symptoms or to monitor disease progression
- CT scan, MRI, SPECT
- ECG: if cardiovascular disease suspected
- EEG: if fronto-temporal lobe dementia or CJD is suspected or where seizure activity is a possibility
- Lumbar puncture: if meningitis or CJD is suspected
- Genetic tests: for Huntington’s disease and familial dementia
- Cognitive assessment: MMSE, AMT, ACE, GPCOG, MOCA
15
Q
What is the general advise for patients with Dementia?
A
- Requirement for patient to inform DVLA.
- Early discussion to allow advance planning before cognition deteriorates. Topics include advance statements or decisions, lasting power of attorney and preferred place of care plans. In later stages of disease MCA 2005 can be enacted to allow decision in the patients’ best interest if provisions haven’t been made
- Vascular dementia preventable and modifiable by targeting CVD risk factors
