Delirium, dementia, and depression Flashcards
What is delirium
- Acute confusional state
- A serious acute neuropsychiatric syndrome characterized by inattention and acute cognitive dysfunction
- Delirium is a symptom of the underlying condition
- Life threatening condition in hospitalized adults
- 30-40% of delirium is preventable and can be reversed
- Marker of an unhealthy brain in an unhealthy body
Epidemology of delirium
- It is common; Prevalence on medical wards in hospital between 20-30%
- Up to 50% in hip surgery patients
- Prevalence in Emergency Departments of 7-17% of all patients
Why the diagnosis of delirium is important
Delirium is independently associated with significant increases in.
• functional disability
• institutionalization
• rates of death
Delirium may be the only sign of significant medical illness such as: • Pneumonia • Sepsis • Abdominal infection • Intra-cerebral event • Acute cardiac event
- It is unclear why some people develop delirium and why others do not
- 2 yr post follow up 55% will have dementia
Consequences of delirium
- Full recovery
- Functional impairment
- Increased costs
- Institutionalization
- Long-term cognitive impairment
- Psychological stress
- Prolonged hospitalization
- Death
Non-modifiable risk factors of delirium
- Dementia or cognitive impairment
- Multiple comorbidities
- Advancing age (>65 years)
- History of delirium, stroke, neurological disease, falls or gait disorder
- Chronic renal or hepatic disease
- Male sex
Potentially modifiable risk factors of delirium
- Sensory impairment (hearing or vision)
- Immobilization (catheters or restraints)
- Medications (for example, sedative hypnotics, narcotics, anticholinergic drugs, corticosteroids, polypharmacy, withdrawal of alcohol or other drugs)
- Acute neurological diseases (for example, acute stroke [usually right parietal], intracranial hemorrhage, meningitis, encephalitis)
- Intercurrent illness (for example, infections, iatrogenic complications, severe acute illness, anemia, dehydration, poor nutritional status, fracture or trauma, HIV infection)
- Sustained sleep deprivation
- Metabolic derangement (e.g. diabetes)
- Surgery
- Environment (for example, admission to an intensive care unit)
- Pain
- Emotional distress
Causes of delirium
- Almost any medical illness, intoxication, or medication can cause delirium
- Delirium is often multifactoral in etiology and each potential cause should be investigated
Delirium causes : I WATCH DEATH
I - infections W - withdrawal A - acute metabolic T - toxins, drugs C - CNS pathology H - hypoxia D - deficiencies E - endocrine A - acute vascular T - trauma H - heavy metals
Delirium causes: DELIRIUM
D - dementia E - electrolyte disorders L - lung, liver, heart, kidney, brain I - infection R - Rx drugs I - injury, pain, stress U - unfamiliar environment M - metabolic
Delirium presentation
- 3 variants of psychomotor behaviour associated with delirium:
- Develops over hours to days
- Hyperactive - “agitated”
- Hypoactive - “sleepy, difficult to rouse”
- Mixed -(hyperactive and hypoactive)
Key clinical features of delirium
- Inattention
- Disorganized thinking
- Altered level of consciousness • Cognitive deficits
- Perceptual disturbances
- Psychomotor disturbances
- Altered sleep cycle
- Emotional states
Why do we not notice delirium?
• Unrecognized by up to 70 % of physicians and health professionals
- We don’t think about the time course (“What has changed?”)
- We assume (incorrectly) that most older people have baseline cognitive
- We usually have a static snapshot of a condition that is by definition fluctuating
- We under-estimate the severity of the condition and its consequences
- We believe delirium always means agitation whereas hypoactive form is most common
- The diagnosis overlaps with dementia and depression
- The presentations are almost always atypical
- We rarely use formal assessment methods
Delirium superimposed on dementia (DSD)
- The prevalence ranges from 22% to 89% in hospitalized and community dwelling individuals 65 and older
- Occurs when an individual with a pre-existing dementia develops delirium
- DSD is under diagnosed and under treated in hospitalized older adults
Delirium assessment
- Careful history and physical examination
- Goal is to determine etiology and treat the cause
- No cause found in 15-25% of patients
Screening tools available:
• Confusion Assessment Method (CAM)
• Delirium Rating Scale
Confusion Assessment Method (CAM)
BOTH
❑ Criteria 1 – Acute onset and fluctuating course (evidence of an acute change in mental status from baseline)
❑ Criteria 2 – Inattention (difficulty focusing attention)
PLUS ONE OF:
❑ Criteria 3 – Disorganized thinking (rambling, incoherent, illogical flow of ideas)
OR
❑ Criteria 4 – Altered level of consciousness (alert, vigilant, lethargic, stupor, coma)
Warning words during delirium assessment
When these words are heard during your practice they should trigger the thought of delirium as a symptom.
- “Not feeling/acting right“
- “Weak“
- “Just not him/herself“
- “Vague complaints“
- “Little old lady with confusion in no apparent distress“ or “pleasantly confused”
- “Well, she looks okay to me…but…”
Nursing assessment for delirium
Gather additional details about dementia/cognitive decline by assessing the following every 8-12 hours at least: 1. Level of consciousness 2. Attention 3. Orientation 4. Thought process 5. Memory 6. Perception (hallucinations/illusions) 7. Sleep/wake cycle 8. Affect
Behaviours:
- Motor behaviour
- Verbal or physical aggression/agitation
- Resistance to care
- Wandering /exit seeking
Delirium management
- Treat cause
- Non-pharmacologic
- Pharmacologic
Finding the underlying cause of delirium
- Take a thorough history
- Always hard given patient is confused
- You will almost certainly need outside help/collateral
- Usually have to call family, review the EMR system carefully, contact the nursing home, and/or other contacts as appropriate (social work, nursing staff who have interacted with the patient, friends who accompany the patient)
- Don’t forget confidentiality/privacy!
Typical investigations for delirium - blood work/rads/other
Routine blood work almost always indicated, more specific based on medications/clinical concerns
• White blood cell count, hemoglobin, potassium, sodium, creatinine, lactate/VBG (if concerns re sepsis), extended lytes as appropriate, liver function and/or enzymes
• If on particular medications check blood levels, ex. vanco (may not have trough level but that’s ok), digoxin, dilantin, etc.
ECG
Xrays/CT
• Focal points of pain, decreased ROM of joints, disfiguration, if head injury or stroke suspected
Urine analysis/culture
Non-pharmacological strategies for delirium
Therapeutic communication strategies
• Establish person’s primary language
• Orientation - Introduce self, offering day, date, time, and place during each interaction
Strategies to reduce internal stressors
• Control pain
• Support nutrition and fluid intake; Restore sleep pattern
Strategies to reduce external stressors
• Reduce environmental stimulation → Place patient in private room away from busy/noisy areas of the unit
• Avoid physical restraints, use observers if possible
Involve the family/caregiver in the plan of care when capable, willing, and appropriate
• Ask family to bring in pictures or familiar objects (eg, favourite hat, pictures)
Strategies to promote patient safety
• Keep environment uncluttered and eliminate environmental hazards
Control disruptive behaviours - Diversion activities, music
Pharmacological treatment for delirium
- Medication review – Are the meds consistent? Is a medication missing? Are the doses correct?
- Medications to treat symptoms such as agitation (e.g. benzo, anti-psychotic)
Prevention of delirium
Targeted interventions
• Reduce incidence of delirium
• Reduce duration of delirium
- 30-40% of cases may be prevented
- Delirium is now being considered a quality indicator for hospital care (like fall rates)
- HELP program – cut incidence in half; bundle of simple interventions: keep patient oriented, meeting their needs for nutrition, fluids, sleep; keeping them mobile.
Nursing considerations for prevention of delirium
- Continuation of care; disruption to their normal
- Sleep deprivation
- Immobility
- Visual impairment; Hearing impairment
- Dehydration
- Cognitive impairment
Nursing care to prevent delirium
- Orientation and therapeutic activities
- Early mobilization
- Minimize use of psychoactive drugs
- Prevent sleep deprivation
- Adaptive methods (eye glasses and hearing aids)
- Early treatment of volume depletion
Dementia vs delirium
Dementia • Multiple underlying etiologies • Chronic and slowly progressive • Non-reversible • Cannot be diagnosed in a patient with delirium
Delirium • Multiple underlying etiologies • Acute and rapidly progressive • Usually reversible • May be diagnosed in a patient with dementia • Medical emergency
Dementia; DSM5 (major neuro-cognitive disorder)
- Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains
• such as complex attention, executive function, learning, memory, language, perceptual-motor or social cognition
This evidence should consist of:
• Concern of the individual, a knowledgeable informant (such as a friend or family member), or the clinician that there’s been a significant decline in cognitive function; and
• substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing. Of if neuropsychological testing isn’t available, another type of qualified assessment.
- The cognitive deficits interfere with independence in everyday activities (e.g., at a minimum, requiring assistance with complex instrumental activities of daily living, such as paying bills or managing medications).
- The cognitive deficits don’t occur exclusively in context of a delirium, and are not better explained by another mental disorder.
Normal age related changes in memory
- Modest increase in processing time
- Increased emphasis on relevance
- Increased distractibility
Risk factors for dementia
- Increasing Age
- Family history
- Smoking
- High cholesterol
- Diabetes
- Untreated depression
- Alcohol
10 warning signs of dementia (Alzheimer’s society of Canada)
- Memory loss affecting day-to-day abilities
- Difficulty performing familiar tasks
- Problems with language
- Disorientation in time and
- Impaired judgment
- Problems with abstract thinking
- Misplacing things
- Changes in mood and behaviour
- Changes in personality
- Loss of initiative
Types of dementia
- Alzheimer dementia (AD) > 60%
- Vascular dementia (VaD)
- 3-4 months post stroke
- More abrupt step wise deterioration
• Parkinson dementia
- Motor aspects
• Frontotemporal dementia (FTD)
- More disinhibited
• Lewy body dementia (LBD)
- fluctuations throughout day
- prone to hallunications
• Mixed dementia; dementia related to HIV or alcohol
Stages of dementia
• Different staging systems exist (e. g. Reisberg Functional Assessment Staging (FAST) Scale out of 16)
3 stage model
• Mild - forgetfulness and misplacing things. Word finding difficulty. Person can still function rather independently and requires little care assistance. May require help with IADLs (especially more complex). Judgment can be impaired
• Moderate - increased confusion, greater memory loss, and worsening judgment. May not recall all personal info. May need help with some ADLs (bathing, dressing, grooming). May notice changes in sleep patterns, as well as in their personality and behaviour
• Severe – Individuals often lose the ability to communicate fluently or engage in conversation, though they may still be able to speak. Decline in physical capabilities, including difficulty eating and swallowing, inability to control bladder and bowel movement, and difficulty walking 7-9 years.
Screening tools in dementia
Commonly used tools:
- Mini-Cog + Clock drawing
- Mini-Mental State Examination (MMSE)
- Montreal Cognitive Assessment (MoCA)
