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RC Study > Delirium CBM and Oxford > Flashcards

Delirium CBM and Oxford Flashcards

1
Q

Delirium diagnosis

A

DSM5

1. Disturbance in attention

  1. Develops over short period of time, change from baseline. Fluctuates.

3. Must also have one disturbance of:

  • memory deficit
  • disorientation
  • language
  • visuospatial ability
  • perception

4. Not better explained by neurocognitive disorder.

  1. Evidence it is caused by medical condition.
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2
Q

Confusion Assessment Method Deliriuj diagnosis

A
  • acute onset
  • fluctuating course
  • inattention
  • and one of:
    • disorganized thinking
    • altered LOC
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3
Q

List clinical subtypes of delirium

A
  • Hyperactice
  • Hypoactive
  • Mixed

Most common hypoactive and mixed in pall care

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4
Q

List reasons why making the diagnosis of delirium is challenging

A
  • ambiguous terms
  • failure to regularly screen for it
  • fluctuation in symptoms
  • hypoactive hard to recognize
  • dementia may contribute
  • depression
  • mania/psychosis/anxiety/akasthisa
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5
Q

List risks if delirium is missed

A
  • increased morbidty
  • using benzo can increase delirium - mistreatment
  • opioids for “pain” that is delirium = OIN
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6
Q

History in delirium

A
  • collateral history
  • onset
  • fluctuation?
  • formal cognitive assessment
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7
Q

Physical exam in Delirium

A
  • vital signs
  • OIN
    • hallucinations
    • hyperalgesia
    • allodynia
  • neuro exam
    • focal or unilateral signs
    • CN
    • asterixis
    • myoclonus
    • babinksi
    • gait
    • frontal primitive reflexes
  • specific causes of delirium : infection, dehydration
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8
Q

Formal cognitive assessment in delirium : tools

A

Screening:

  • RASS-PAL
  • CAM
  • BOMC

Diagnosis:

  • DSM5
  • CAM

Monitoring

  • RASS-PAl
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9
Q

Etiology of Delirium in Advanced Cancer

A
  • Intracranial disease
    • brain tumour
    • LMD
    • seizure/post ictal
  • Medications
    • benzos
    • opioids
    • tcs
    • SSRI
    • antipsychotics
    • anticholingerics
    • antihistamines
    • steroids
    • cipro ???
  • Organ Failure
  • Infection
  • Heme
    • anemia
    • DIC
  • Metabolic
    • Dehydration
    • hypercalcemia
    • hyponatremia
    • hypoglycemia
    • hyperglycemia
  • Paraneoplastic
    • encephalitis
  • Withdrawal
    • opioids
    • benzos
    • ETOH
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10
Q

List risk factors for delirium in cancer

A
  • malnutrition, low albumin
  • advanced age > 70
  • pre-existing cog impairment
  • prior delirium
  • polypharmacy
  • urinary retention, constipation
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11
Q

Pathogenesis

A
  • acute brain failure
  • impaired cerebral oxidative metabolism
  • multiple neurotransmitter abnormalites
    • High DOPAMINERGIC tone
      • dopamine increase in mesolimbic tract
      • agitation and delusions
    • Low CHOLINGERIC TONE
      • hippocampus and basal forebrain
      • Disorientation, hallucinations, memory impairment
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12
Q

How do opioids increase risk for delirium?

A
  • Morphine metabolites
    • M3G
  • Hydromorphone metabolite
    • H3G
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13
Q

List impacts that delirium can have on patients and families

A
  • palliative emergency
  • distressing
  • loss of capacity
  • loss of meaningful communication
  • difficulty assessing pain
  • frustration
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14
Q

List common deliriogenic drugs in palliative care

A
  • Anticholingerics (scopolamine, diphenhydramine)
  • TCAs
  • Anti inflammatories
  • Benzos
  • Diuretics
  • GI meds (ranitidine)
  • Opioids
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15
Q

Prognosis of delirium in pall care

A
  • reversibility up to 50%
  • terminal delirium very poor prognosis
    *
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16
Q

Investigations for delirium

A
  • CBC
  • lytes
  • urea/Cr
  • Calcium
  • albumin
  • Mg
  • glucose
  • liver enzymes
  • B12/folate
  • TSH
  • CRP
  • ECG
  • Urine and culture
  • Cxray
  • blood cultures
  • brain CT/MR
  • LP
17
Q

Life threatening Causes of Delirium

A

WHHHIMP

  • Wernicke’s
  • Hypoxia
  • Hyper/hypoglycemia
  • Hypertensive Encephalopathy
  • Intracerebral hemorrhage
  • Meningitis /encephalitis
  • Poisoning
18
Q

Differential Diagnosis Delirium (general)

A

I WATCH DEATH

Infection

Withdrawal - etoh, opioids,

Acute metabolic - hyperCa++, Na, liver, renal failure

Trauma

CNS pathology - stroke, tumour, mets, post ictal

Hypoxia - CHF, anemia

Deficiencies - thiamine, B12, niacian, folate

Endocrine - Hypoglycemia

Acute Vascular - hypertension, hypotension

Toxins - drugs

Heavy Metal

19
Q

Differential DIMES

A

DIMES

  • Drugs
  • Infections
  • Metabolic
  • Environmenta
  • Structural/Seizures/Systemic illness
20
Q

General approach to delirium management

A
  • address goals of care
  • decide to work up and treat reversible causes if relevant
  • educate patient and family
  • non pharmacologic interventions
  • medications for symptoms
  • reduce polypharmacy
21
Q

List non pharmacological Tx for delirium

A
  • frequent orientation of patient
  • oral hydration
  • hearing aids/glasses
  • attention to light /window
  • sleep hygiene
  • consistent caregivers
  • daily routine
  • limit immobilization
  • limit restraints
22
Q
A
23
Q

Approach to behavioural disturbances

A
  • remove things that aggravate it
  • treat medical/physical issues first (pain, hunger, thirst)
  • Don’t argue
    • reassure
    • distract to something pleasant
24
Q

Antipsychotics in delirium

A
  • Haldol first line
  • 0.5mg-1mg po/sc/iv q30 min until agitation settled
  • maintenance dosing od to bid
    • slowly taper over 5 days

Methotrimeprazine

  • 6.25-12.5 mg sc q4h (max 100 mg/day)

Quetiapine

  • 12.5-25 mg po or bid/tid

Olanzapine

  • 2.5 mg bid

Risperdone

  • 0.25-0.5 mg po bid
25
Q

General side effects of most antipsychotics

A
  • NMS
  • Qtc prolongation
    • >450 CAUTION
    • > 25% increase in Qtc after starting–> stop
  • EPS
  • Black box warning on many
26
Q

Extrapyramidal Symptoms

A
  • Dystonia (abnormal spasms, muscle contractions)
  • Akathisia (restlessness)
  • Parkinsonism (rigidity, tremor, bradykinesia)
  • Tardive dyskinesia (irregular, jerky movements)

Dopamine deficiency from dopamine antagonism from antipsychotics, anti-emetics, SSRIs.

27
Q

Common medications that cause EPS

A
  • Typical antipsychotics
    • haldol
    • chlorpromazine
    • prochlorperazine
  • Methotrimeprazine
  • Atypical antipsychotics
    • Risperdone - worst offender
    • Quetiapine - low risk
    • Olanzapine - low risk
  • Anti emetics
    • Metoclopramide
  • Antidepressants:
    • SSRIs
    • SNRIS
    • NDRIS
28
Q

How to treat delirium in Lewy Body Dementia

A
  • AVOID FIRST GEN ANTIPSYCHOTICS
    • causes irreversible parkinsonism
    • impaired consciousness
    • death?
  • If really needed, use atypicals cautiously
  • Risperdone preferred

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