Delirium (..and dementia)

Question 1

Addenbrookes (ACE):

- 5 areas assessed

Answer 1

• Attention, Memory, Language, Verbal fluency, Visuospatial function

Question 2

Dementia:

3 core categories of symptoms

Answer 2

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.

Question 3

Mild cognitive impairment

Answer 3

Cognitive impairment but with preservation of functional abilities (ADLs unaffected)

Question 4

AD:

a) Earlier symptoms
b) Later symptoms

Answer 4

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

Question 5

Treatable causes of dementia

Mnemonic: DEMENTIA

Answer 5

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

Question 6

Test to distinguish between subtypes of dementia (if not obvious on clinical grounds)
- not useful in context of what condition?

Answer 6

SPECT

Down’s syndrome

Question 7

Condition with a triad of:
Dementia, Diarrhoea, Dermatitis
- cause?

Answer 7

Pellagra

Vit B3 deficiency

Question 8

Delirium: define

Answer 8

Delirium is defined as an acutely altered and fluctuating mental status with features of inattention and an altered level of consciousness

Question 9

Donepezil:

a) Indication
b) 4 cautions

Answer 9

a) Mild-moderate dementia

b) Asthma, COPD, sinus bradycardia, heart block

Question 10

Memantine

a) Indication
b) Main risk

Answer 10

a) Mod-severe dementia

b) Falls due to dizziness and balance impairment

Question 11

Diagnosing delirium
Confusion Assessment Method (CAM):
- Core features - AIDS
- Supporting features - AIDS

Answer 11

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

Question 12

Delirium

a) Hypoactive - 2 core symptoms, DD?
b) Hyperactive - 3 core symptoms, DD?
c) Incident
d) Prevalent

Answer 12

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

Question 13

Delirium on dementia: causes

a) Predisposing factors
b) Precipitating: OH PINCH ME

Answer 13

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)

Question 14

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?

Answer 14

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

Question 15

Delirium: investigations (1st and 2nd line)

a) B
b) O
c) X
d) E
e) S

Answer 15

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

Question 16

Delirium: management

a) Must be an assessment of…?
b) Treat the…?
c) 4 management categories: MEDS

Answer 16

a) Capacity - 5 principles (presume, support, unwise, best interests, least restrictive)
b) Treat the underlying cause!
c) Medical, Environmental, Discharge, Supportive

Question 17

Delirium: medical management

Answer 17

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)

Question 18

Delirium: environmental management

• Things to control in the room/environment
• Things to maintain in the patient

Answer 18

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

Question 19

Delirium: discharge planning

- Points to note/tell family

Answer 19

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

Question 20

Drug-induced delirium: management

Answer 20

• 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

Question 21

Drug-induced delirium:

a) Common offending drugs
b) Management

Answer 21

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

Question 22

Delirium: prevention

• Mnemonic: MIASMA
• and… beware of PINCH ME causes

Answer 22

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.

Question 23

Delirium: complications

Answer 23

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

Question 24

AMT

a) Questions
b) Scoring
c) Who should be assessed?

Answer 24

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

Question 25

Agitation in delirium:

a) possible causes
b) when to treat (sedation)
c) sedative options
d) best option in PD

Answer 25

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

Question 26

First line treatment for disorientated patients wandering around a ward

Answer 26

Regular reassurance and orientation – so long as they do not find this distressing

Question 27

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?

Answer 27

Sedation - IM Lorazepam

Question 28

Treatment of urinary retention

a) Acute
b) Chronic

Answer 28

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)

Question 29

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?

Answer 29

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