Delirium, Immobility & Falls & Ageing & Frailty Flashcards
What is delirium and what are the key features of it?
Delirium=acute change in your mental state
Key features:
Disturbed consciousness-Hypoactive/hyperactive/mixed
Change in cognition- Memory/perceptual/language/illusions/hallucinations
Acute onset and fluctuant
What are other common features of delirium?
Disturbance of sleep wake cycle
Disturbed psychomotor behaviour – DELIRIUM AFFECTS YOUR PHYSICAL FUNCTION
Emotional disturbance
Does anyone really know why delirium happens?
Not really
Maladaptive pro inflam state-as get older brain is a bit leakier and as you develop cognitive frailty brain gets even leakier again – much more likely to get delirium in response to some sort of external stimuli at advances of age and frailty than you are likely to have at younger ages
What precipitates delirium?
Infection (but not always a UTI!)
Dehydration
Biochemical disturbance
Pain
Drugs
Constipation/Urinary retention
Hypoxia
Alcohol/drug withdrawal
Sleep disturbance
Brain injury-Stroke/tumour/bleed etc
Changes in environment/emotional distress
Sometimes no idea and often multiple triggers!
Antidepressants are associated with falls
Dihydrocodeine for knee pain (flare of arthritis)-well recognised side effect is constipation
Urinary retention because of constipation, already has prostate problems – bit predisposed to bladder outflow problems
How common is delirium?
Commonest complication of hospitalisation
20-30% of all in-patients
Up to 50% of people post surgery
Up to 85% of people at end of their life
Why is delirium important?
- Massive morbidity & mortality
- Increased risk of death
- Longer length of stay
- Increased rates of institutionalisation
- Persistent functional decline
How is delirium diagnosed?
4AT-Delirium Screening Tool
Everyone >65 when admitted to hosp should have one
What should be done when find delirium?
Treat the cause
- Full Hx and exam (incl. neuro)
- TIME bundle-helps to manage triggers
Explain the diagnosis!
Pharmacological measures
Non-pharmacological measures
What are the non-pharmacological treatments for delirium?
Re-orientate and reassure agitated patients- USE FAMILIES/CARERS
Encourage early mobility and self-care
Correction of sensory impairment
Normalise sleep-wake cycle
Ensure continuity of care
- Avoid hospitalisation if possible
- avoid frequent ward or room transfers
Avoid urinary catheterisation/venflons
Discharge people (if in hospital) ASAP
What pharmacological managements are appropriate for delirium?
- Drug treatment for delirium usually not necessary
- Stop bad drugs
Only if danger to themselves or others or distress which cannot be settled in any other way
Start low and go slow
12.5mg quetiapine orally
THIS SHOULD BE A CONSULTANT/REGISTRAR DECISION
Is delirium preventable?
Preventable in 30% of cases
Risk reduction for those at risk such as pain control, early mobilisation, maintaining hydration & nutrition etc
What does the delirium trajectory & follow up look like?
- Usually settles quickly with management of underlying causes
- May unmask previously undiagnosed cog impairment
- More likely to go on & develop dementia
- Risk factor for further episodes delirium/dementia/frailty syndromes so remember to record and communicate diagnosis and organise follow up
Recognise people at high risk-may influence what drugs are prescribed and what kind of community based models of care are offered to try and keep these people as fit & well and out of hospital
Is capacity decision specific?
Yes
- Legally appointed proxy decision maker can be welfare POA or guardian
Is there association between delirium & falls?
4.5x more likely to fall if have delirium
Delirium prevention interventions also reduce falls
If stop people moving-much more likely to fall – promoting mobility is very important
Why are so many UTIs overdiagnosed?
High prevalence of asymptomatic bacteriuria in older adults
Asymptomatic bacteriuria-people who if you dip their urine will have leukocytes and nitrites or will grow bug in the lab-but these people do not have an active infection.
What should not be used to diagnoses UTI in older people?
Dipstick tests
How do drugs cause falls?
DECREASE:
- BP
- HR
- Awareness
INCREASE:
- Urine output
- Sedation
- Hallucinations
- qTC
- Dizziness
What are the culprit drugs that can be responsible for falls?
Antihypertensive
Beta blocker
Sedatives
Anticholinergics
Opioids
Alcohol
- Lots of older people cure their own HT just by losing weight – frailty
How does where you are affect how you deal with a fall?
Falls clinic (full MDT)-Likely to be well patients, difficult and multifactorial falls
A+E - More likely to be acutely unwell. May not be possible to do it all
Assessing a hospital inpatient who has fallen - Very likely to be acutely unwell. Significant injury possible
What does syncope on exertion make you think of?
Aortic Stenosis
What is important to cover in a systematic enquiry in addition to the usual things?
Memory – Ideally ask a relative too
Urinary symptoms (they won’t tell you if you don’t ask)
Has walking changed recently
Drugs
Especially over the counter antihistamine
Especially alcohol
Falls examination: What is important to look for in head and arms?
Cerebellar signs
Bradykineasia, ridigidity – signs of PD
What will happen to the centre of balance in Kyphosis?
Kyphosis-centre of balance will be effected – postural instability
Falls examination: What to do with legs should be examined?
- Peripheral neuropathy – vibration sense
Look at feet (footwear, toenails).
Check sensation, vibration sense, and proprioception – remember usually glove and stocking not dermatomal
Co-ordination
Put shoes and socks back on. (You may need a shoehorn)
Stand patient up.
Romberg’s
Assess gait
What does each of these gaits mean in terms of a pathology…
1)Ataxic
2)Arthralgia
3)Hemiplegic
4)Small steps, shuffling
5)High stepping?
1)Cerebellar damage
2)Arthritis
3)Stroke
4)(Vascular) parkinsonism
5)Peripheral neuropathy
Those non injured fallers what often happens?
Often left at home by paramedics and referred to community falls pathways- including falls clinic
If a person who has fallen was lieing down for a long time what should be checked?
Long lie – check CK for rhabdomyolysis. Pneumonia and skin injury common as well.
Does a head injury with no neurological signs need a CT head?
NO
Consider CT head if fall with head injury and neurological signs or anticoagulated
What bloods should be checked in all falls patient?
B12, folate, CK, TFTs
ECG for all too
How to assess a fallen patient?
- ABCDE approach
- Check glucose
- Top to toe survey
What should be included in the immediate assessment for serious injuries?
- Head injury & extra dural
- Seizure
- C spine injury
- Flail chest
- Abdo injury
- Flail chest
- Pelvic injury
- Limb fracture
What are things not to miss after an inpatient falls?
- SDH – fall may not have an obvious head injury and they may become confused a few days later
- Fractured neck of femur – shortened and externally rotated
When should you CT a head injury immediately?
Low GCS <13
Still confused after 2 hours (or not back to baseline cognitive state)
Focal neurology
Signs of skull fracture
Basal skull fracture – CSF leak, bruising around eyes,
Seizure
Vomiting
Anti-coagulation
When should an xray be performed?
If pain on moving a joint have low threshold of x ray
If no deformity but pain on weight bearing have low threshold to x ray
- People can walk on fractured hips
Septic patients get … blood sugar
LOW
What are the nurses actions post-fall?
Repeat risk assessment
Datix
Call family
Try and prevent further fall-fall prevention care plan (ensure vision and mobility aids and call bed are in reach, consider bed rails, regular obs)
Why is ageing beneficial, neutral and detrimental?
Beneficial
Increased experiential learning
Neutral
Grey hair
Pastime preference
Detrimental
Hypertension, decreased reaction time-comorbidities
What are the theories of ageing?
Stochastic:
Cumulative damage (because of micro trauma and free radicals)
Random
Programmed:
Predetermined
Changes in gene expression during various stages
Homeostatic failure-less reserve to cope with any given environmental challenge so are less able to maintain homeostasis
Describe the physiology of ageing?
- Affects virtually every organ/system
- Marked inter-individual variability in both development and magnitude of changes
- Inter-individual variability INCREASES with age
- Evidence very limited for 80+
What happens to the kidneys as we age?
- Poorer clearance in creatinine
- Accompanied by reduction in muscle bulk
What is dyshomeostasis and what is frailty according to this?
The point of physiology is to maintain a steady state-Impaired function of any organ system makes this more difficult
Frailty is effectively progressive dyshomeostasis
What is frailty and what frailty syndromes can it result in?
A susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge
This results in “Frailty Syndromes”:
Falls
Delirium
Immobility
Incontinence
What do carotid sinuses detect changes in?
BP
Who is more likely to present with HYPOTHERMIA & HEAT STROKE?
Those with FRAILTY
What happens to measure of sway as we age?
Measure of sway when standing-older age groups sway more as less able to keep homeostasis in tight limits (cant correct as well for slight changes in weight when standing)
What is ‘social’ dyshomeostasis?
Difficulty caused by environmental insults not only bio-medical
Ageing often associated with whole system dyshomeostasis
Different ability to compensate for e.g. death of spouse or daughter going on holiday
Humanity relies on the social structures around us to keep us well – tend to degrade as we get older
How may Hyperthyroidism classically present compared to how it presents in a person with frailty?
Classic presentation:
Tremor
Anxiety
Weight loss
Diarrhoea
Person with frailty:
Depression
Cognitive impairment
Muscle weakness
Atrial fibrillation
Heart failure
Angina
What are the practical implications of an increasingly ageing population?
Increasing number of older people with multiple co-existing medical conditions
Increased inter-individual variability in organ function and homeostatic reserve
Different presenting symptoms and signs
-Presentation of different “illnesses” can be v similar
Multimorbidity and frailty are different but are both issues for older people
What are the practical implications of an increasingly ageing population?
Increasing number of older people with multiple co-existing medical conditions
Increased inter-individual variability in organ function and homeostatic reserve
Different presenting symptoms and signs
-Presentation of different “illnesses” can be v similar
Multimorbidity and frailty are different but are both issues for older people
Relatively little evidence of drug efficacy and safety for patients 80+
- Pre-marketing development still largely involving young and middle age pts with fewer co-morbidities
Multiple medications:
Drug-drug interactions
Adverse drug reactions
