Delirium (..and dementia) Flashcards
Addenbrookes (ACE):
- 5 areas assessed
- Attention, Memory, Language, Verbal fluency, Visuospatial function
Dementia:
3 core categories of symptoms
Cognitive - memory, orientation, language, executive function
Behavioural/psychiatric: personality change, depression, inhibitions lost, agitation, hallucinations, emotional control lost
Functional - activities of daily living - difficulty driving, eating, walking, getting dressed and showered, etc.
Mild cognitive impairment
Cognitive impairment but with preservation of functional abilities (ADLs unaffected)
AD:
a) Earlier symptoms
b) Later symptoms
a) Word finding difficulty, forgetting appointments, forgetting names of people and places, difficulty remembering recent events (short term memory loss)
b) Apraxia, confusion, agitation, wandering, disorientation, Psych (apathy, depression, hallucinations, delusions), Behavioural (disinhibition, aggression, agitation) altered eating habits, incontinence
Treatable causes of dementia
Mnemonic: DEMENTIA
Drugs (intoxication, withdrawal, TCAs,
Emotional (depression, anxiety)
Metabolic (hypothyroid, electrolytes, liver disease, kidney disease, hypercalcemia)
Eyes and ears (sensory deprivation)
Normal pressure hydrocephalus, Nutrition (B12, iron)
Trauma, tumours (and chronic SDH)
Infection (abscess, encephalitis, syphilis, HIV)
Arteriosclerosis / vascular disease
Test to distinguish between subtypes of dementia (if not obvious on clinical grounds)
- not useful in context of what condition?
SPECT
Down’s syndrome
Condition with a triad of:
Dementia, Diarrhoea, Dermatitis
- cause?
Pellagra
Vit B3 deficiency
Delirium: define
Delirium is defined as an acutely altered and fluctuating mental status with features of inattention and an altered level of consciousness
Donepezil:
a) Indication
b) 4 cautions
a) Mild-moderate dementia
b) Asthma, COPD, sinus bradycardia, heart block
Memantine
a) Indication
b) Main risk
a) Mod-severe dementia
b) Falls due to dizziness and balance impairment
Diagnosing delirium
Confusion Assessment Method (CAM):
- Core features - AIDS
- Supporting features - AIDS
Core features:
A - Acute onset/fluctuating course, AND…
I - Inattention (e.g. 20 to 1 test, distractible), AND…
D - Disordered thoughts/perceptual changes, OR…
S - Sleepy/stuporous (consciousness affected)
Other features: A - Agitation/retardation (psychomotor) I - Impaired memory D - Disorientation S - Sleep/wake cycle impaired
Delirium
a) Hypoactive - 2 core symptoms, DD?
b) Hyperactive - 3 core symptoms, DD?
c) Incident
d) Prevalent
a) Apathy and quiet confusion are present and easily missed. This type can be confused with depression.
b) Agitation, delusions and disorientation are prominent and it can be confused with schizophrenia.
c) Onset during admission
d) Onset prior to admission
Delirium on dementia: causes
a) Predisposing factors
b) Precipitating: OH PINCH ME
a) Frailty, Dementia, Age, Sensory impairment, Co-morbidities, Polypharmacy
b) Operative (especially hip# repairs), Hypo/hyperthermia, Pain, INfection, Constipation, deHydration, Metabolic, Environmental (drugs 50%, alcohol, change of environment)
Assessment of delirium
a) ABCD and what bedside tests particularly?
b) History and examinations
c) Confusion Assessment Method (CAM) - 4 criteria (AIDS)
d) What is in the 4AT?
e) MMSE - 4 domains assessed (ORAL)
f) Who should be assessed using AMT?
a) Conscious level (GCS). Vital signs - e.g, pulse oximetry, HR, BP temperature. Capillary blood glucose +/- urine dipstick if clinically indicated
b) Collateral history often necessary (premorbid state, predisposing factors, preciptitants, etc.) Examinations: CV, resp, abdo (inc. bladder for retention), neuro, ENT, PR (for impaction), any wounds/skin infections
c) Acute onset/fluctuating course AND Inattention (e.g. on 20 to 1 test) AND 1 out of… Disorganised thought OR Stuporous/consciousness reduced
d) AMT-4, Alertness, Attention, Acute change or fluctuating course?
e) Orientation, Registration and recall, Attention, Language
f) Everyone over 65 in hospital
Delirium: investigations (1st and 2nd line)
a) B
b) O
c) X
d) E
e) S
a) 1st line: FBC, U and Es and creatinine, glucose, calcium, LFTs, TFTs, cardiac enzymes, vitamin B12
2nd line: blood gas, blood cultures, syphilis serology, autoantibody screen and PSA
b) 1st line: Urine dipstick +/- MSU, 2nd line: other specific swabs/samples (e.g. sputum, stool, HVS)
c) 1st line: CXR, 2nd line: CT head, AXR
d) 1st line: ECG, 2nd line: EEG
e) 2nd line: LP
Delirium: management
a) Must be an assessment of…?
b) Treat the…?
c) 4 management categories: MEDS
a) Capacity - 5 principles (presume, support, unwise, best interests, least restrictive)
b) Treat the underlying cause!
c) Medical, Environmental, Discharge, Supportive
Delirium: medical management
Medical:
- in agitated patients not responding to verbal and non-verbal de-escalation techniques. May try olanzapine or haloperidol (lowest dose for shortest time, ideally < 1 week). In alcoholics with DTs: chlordiazepoxide
- analgesia (but avoid opiates if possible)
Delirium: environmental management
- Things to control in the room/environment
- Things to maintain in the patient
Avoid over- or under-stimulation. Adequate space and sleep. Single rooms if possible. Control excess noise. Control room lighting and have a low-wattage bulb at night. Control room temperature.
Maintain competence - e.g, maintain walking in ambulant patients. Adequate nutrition and attention to continence
Allow wandering - use the least restrictive option and prevent agitation
Delirium: discharge planning
- Points to note/tell family
The symptoms of delirium may last longer than the underlying condition (e.g. disorientation, inattention and depression)
Families and carers may also need to be supported and given advice and reassurance
Drug-induced delirium: management
- Stop offending medications (often difficult to know culprit but could be suggested by temporal relationship between drug initiation/increase dose and symptom onset
- Reduce doses/withdraw all unnecessary medications that may be causing delirium
Drug-induced delirium:
a) Common offending drugs
b) Management
a) BDZs, Anticholinergics, Diuretics, Antihistamines, BBs, steroids, statins, antiarrhythmics, TCAs, antiepileptics, opiates
b) - Stop offending medications (often difficult to know culprit but could be suggested by temporal relationship between drug initiation/increase dose and symptom onset
- Reduce doses/withdraw all unnecessary medications that may be causing delirium
Delirium: prevention
- Mnemonic: MIASMA
- and… beware of PINCH ME causes
M - MDT approach to the prevention of delirium.
I - Identify at risk patients
A - Assess patients within 24 hours of admission, making note of factors that may precipitate and worsen delirium.
S - stimulate, sensory awareness (environment)
M - medication review (stop non-essential), metabolic stability
A - analgesia
Other factors include: dehydration, constipation, reduced mobility, infection, poor nutrition, sensory impairment and sleep disturbance.
Delirium: complications
Hospital-acquired infections - eg, Clostridium difficile and meticillin-resistant Staphylococcus aureus (MRSA).
Pressure sores.
Fractures - eg, femoral or hip fractures from falls.
Residual psychiatric and cognitive impairment.
Some progress to stupor, coma and eventual death
AMT
a) Questions
b) Scoring
c) Who should be assessed?
a) Age Time Address for recall Year Name of hospital Recognition of 2 people Date of Birth Year of first world war Name of current monarch Count backwards 20-1
b) < 8 out of 10 is abnormal - warrants further investigation
c) Assess all inpatients over 65
Agitation in delirium:
a) possible causes
b) when to treat (sedation)
c) sedative options
d) best option in PD
a) Pain, Constipation/ need to go to the toilet, Frustration at inability to communicate needs, Being frightened by delusions, hallucinations or misperception
b) distressing symptoms or dangerous behaviour
c) Lorazepam / Olanzapine / Haloperidol (try oral method first, then IM)
d) Avoid haloperidol (EPSEs) - use lorazepam or clozapine
First line treatment for disorientated patients wandering around a ward
Regular reassurance and orientation – so long as they do not find this distressing
A 78 year old man becomes confused and aggressive on the ward 24 hours after admission. He does not respond to behavioural measures and is behaving in a threatening manner towards other patients. What is the most appropriate management?
Sedation - IM Lorazepam
Treatment of urinary retention
a) Acute
b) Chronic
a) Catheterise immediately. An alpha-blocker (e.g. tamsulosin, doxasozin) should be give for at least 2 days before catheter is removed to relax bladder muscles
b) Conservative measures, intermittent catheterisation, alpha-blockers, possible role for cholinsterase inhibitors (e.g. pyridostigmine)
PD patient with delirium.
a) Should L-Dopa be stopped?
b) What medications may be effective?
c) Patient gets agitated, what other medications may be useful?
a) Although levodopa can be associated with delirium, it should not be stopped abruptly as this can precipitate a withdrawal syndrome marked by rigidity and worsening confusion
b) Atypical antipsychotic (quetiapine or clozapine)
c) Lorazepam/ olanzapine
