Delirium Assessment and History - MMSE, 4AT, AMTS

Question 1

4AT

• how would you do this
• how would you interpret this

Answer 1

Alert

• normal OR sleepy on waking, then normal => 0
• abnormal => 4

AMT4 (age, DOB, year, building

• no mistakes => 0
• 1 error => 1
• 2 errors => 2

Attention - months of year backwards

• 7 months or more correct => 0
• U7, does not start => 1
• untestable => 2

Acute/fluctuating course - during last 2wks, still evident in last 24hrs

• No => 0
• Yes => 4

0 - cognitive impairment unlikely but delirium possible if 4 incomplete
1-3 - possible cognitive impairment
4 - possible delirium

Question 2

AMTS (10)

• how would you do this
• interpretation

Answer 2

Age
Time to nearest hour
Give patient an address and ask them to repeat at end of test - 42 West Street
Year
Location
Can they recognise 2 people
DOB
Year that WW1 began
Current monarch/PM
Count backwards from 20-1

U7 - delirium or dementia

Question 3

Delirium vs dementia history

-key questions

Answer 3

Onset and duration
Course
Behaviour - agitated, restless, sleep disrupted?
Memory - sudden or gradual
Visual hallucinations

Any underlying cause?
WHAT IS THEIR BASELINE LIKE

Question 4

Differentiating between delirium and dementia

Answer 4

Delirium core features

• Acute onset
• Fluctuating intensity of symptoms
• Inattention and disorganised thinking
• Reduced consciousness
• Behaviour - hyperactive (agitated, restless), hypoactive (quite, drowsy)
• visual hallcuinations

Dementia core features

• Insidious onset
• Gradual progression of symptoms
• Attention intact, organised thinking unless late
• Conscious
• Behaviour intact unless late
• visual hallucinations in late

Question 5

Causes of delirium

Answer 5

Dehydration, discomfort
Electrolytes, environment
Lack of sleep, lungs (hypoxia)
Infection, infarction
Renal failure
Impaired sensory input (eyes, hearing)
UTI
Metabolic (glucose, thyroid, meds)

Question 6

Delirium vs dementia

• past medical history, drugs, allergies
• social history

Answer 6

Baseline functioning

• ability to care for themselves, cook, clean, shop
• take meds, eat

Living

• who’s at home
• dependents, carers?

Occupation
-work

Substances
-alcohol, smoking, recdrugs

Question 7

Investigations to consider

Answer 7

Bedside

• GPCOG - cognitive assessment, compare with past test if available
• 4AT - assess for delirium
• urinalysis - UTI, hyperglycemia?
• sputum culture - infection

Bloods

• FBC, CRP - infection
• folate, B12 - vitamin deficiency
• LFT - hepatic failure
• TFT - hyper/hypothyroid
• U&E, Ca - electrolyte derangements
• HbA1c - glucose control

Imaging
-CXR - chest infection