Delirium |X Flashcards
What is the definition of delirium?
a “state of mental confusion that develops quickly and usually fluctuates in intensity”
What are the 4 key criteria for diagnosis of delirium based on DSM-IV?
A. Disturbance of attention or arousal/consciousness
B. Worsening confusion
C. Acute onset with fluctuating course, with disturbance of the sleep wake cycle
D. Evidence from the history, examination or investigations that the delirium is a direct consequence of:
i. a general medical condition
ii. substance intoxication
iii. substance withdrawal
iv. multiple aetiologies (often)
What is the definition of arousal?
The magnitude of response to perceived stimuli
What is the definition of cognition?
The mental process of thinking and knowing, including aspects such as awareness, perception, memory, language, reasoning, and deciding
What is the definition of consciousness?
Alertness plus awareness
What is the definition of attention?
The ability to focus the mind, and sustain focus, on an environmental stimulus, idea, or series of connected ideas
What is the definition of awareness?
Self perception or inward sensibility
What is the definition of alertness?
Ability to respond to external stimuli
Criteria A of DSM-IV diagnosis of delirium, how do patients with disturbance of consciousness typically present (2)?
How do you test for it?
- The key is reduced attention, which is the ability to focus, sustain, or shift mental focus.
- Patients demonstrate distractibility, drowsiness, or reduced vigilance.
Mostly you observe it during interview, but can test it with tasks that require concentration e.g. spelling backwards, serial 7’s, digit span.
Criteria B of DSM-IV diagnosis of delirium, how do patients with worsening confusion typically present (2)?
- A change in cognition
e. g. memory deficit, reasoning or language disturbance or mental slowing
OR
- The development of a perceptual disturbance
e. g. hallucinations that is not better accounted for by a pre-existing, established, or evolving dementia
Criteria C of DSM-IV diagnosis of delirium, how do patients with acute onset with fluctuating course typically present (2)?
- The disturbance develops over a short period of time (hours to days)
- It tends to fluctuate during the course of the day, in particular being worse at night.
What are 4 associated features that might present with delirium in addition to the core diagnostic features?
- delusions (often paranoid)
- Delusions tend to be fleeting, and lack any system or logic. - emotional changes (anxiety, fear, depression)
- motor changes (slowness, restlessness, agitation)
- hallucinations (often formed and animated)
Why is hypoacative or apathetic delirium hard to spot?
The patient is quiet, withdrawn, lacks initiative and responds poorly to interaction.
Often mistaken for depression
In delirium, behaviours such as aggression or restlessness are a response to what (4)?
- Pain
- Constipation
- Frustration at inability to communicate needs
- Being frightened by delusions, hallucinations or misperceptions
How common is delirium?
Common
How serious is delirium?
Emergency - It is essential that delirium is treated with seriousness, as it often reflects severe underlying illness and has a high mortality.
What is the prevalence of delirium in hospitals?
20%
How much more likely are patients with dementia to develop delirium?
5-10%
What are 5 negative consequences of delirium?
- Increased mortality (1 year mortality following an admission with delirium is 40%)
- Prolonged hospital admission
- Higher complication rates
- Institutionalization
- 3x increased risk of developing dementia
What are 5 predisposing risk factors and 6 precipitating risk factors of delirium?
Predisposing:
- Dementia
- Sensory impairment e.g. vision
- Older age (>65 years)
- Multiple co-morbidities
- Physical frailty
Precipitating
- Metabolic abnormalities
- Systemic infection
- Surgery
- Drug initiation/withdrawal
- Acute brain disease
- Hypoxia
What are 7 prevention strategies that should be applied to patients at high risk?
- Keep orientated, promote the familiar
- Facilitate vision and hearing (glasses, light, hearing aid)
- Keep hydrated and well fed
- Reduce medication, avoid anticholinergic drugs and opiates
- Keep mobile and active
- Promote night time sleep
- Minimise provocation (noise, tubes, restraints)
What are 3 types of delirium?
What % of cases do each make up?
- Hypoactive - 40%
- Hyperactive - 25%
- Mixed - 35%
How do patients with hypoactive delirium present (4)?
- Apathy
- Withdrawal
- Lethargy
- Reduced motor activity
What are 2 negative consequences of hypoactive delirium?
- Longer hospital stays
2. Higher risk of complications associated with reduced mobility e.g.g pressure sores
How do patients with hyperactive delirium present?
- Increased motor activity
- Associated agitation
- Hallucinations
- Challenging behaviour
How do patients with mixed delirium present?
Patients may have a mixed picture when suffering with delirium and this often will fluctuate during the course of a day.
What is the order of a logical assessment of a patient with delirium (4)?
- History
- Examination
- Investigations
- Management
How is it best to obtain a history from someone with delirium?
An accurate history is often difficult to obtain so seek a collateral history from family members, friends, care home workers, general practitioners or other community health care professionals
-Communicate with your team to avoid everyone repeating the same questions to e.g. the care home
What key details do you need to obtain from the history (9)?
- PC - Onset and course of the confusion
- Symptoms suggestive of underlying cause
- Previous episodes of confusion and how this has progressed
- PMH
- Drug history
- Social circumstances including family and support services
- Sensory deficits
- Functional status
- Alcohol history
Why do you need to examine a patient with delirium?
May direct you to the source of the problem
What 7 examinations do you need to do for derlirium?
- Conscious level
- GCS or AVPU - Cognitive function
- Abbreviated Mental Test Score (AMT) or Mini Mental State Examination (MMSE) - Mental state exam
- Neurological exam including speech
- Constipation
- Abdominal exam
- DRE
- Consider post void bladder scan - Infection screen
- Remove bandages and check pressure areas - Assess hydration and nutrition status
Which routine screening test do you do at acute admissions to check cognitive function?
AMT
What questions do you ask in the AMT (10)?
- Age
- Time
- Address for recall
- Year
- Name of hospital
- Recognition of 2 people
- Date of Birth
- Year of first world war - 1914-1918
- Name of current monarch
- Count backwards 20-1
What score on the AMT is classed as abnormal?
<8
If a patient scores an abnormal score on the AMT, what is done next?
Confusion Assessment Method (CAM)
What does the CAM assessment involve?
What do you need for a diagnosis of delirium by CAM?
Involves assessing a patient for 4 features:
- Acute onset and fluctuating course
- Inattention
- Disorganised thinking
- Altered level of consciousness
Requires presence of features 1 and 2 and either 3 or 4
How would you ask about CAM feature 1 (2)?
Compare with patient’s baseline mental status; info from relatives or carers
Ask a family member or
nurse the question:
- “Is there evidence of an acute change in mental status from the patient’s baseline?”
- Does the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
How would you ask about CAM feature 2 (1)?
Does the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what is being said?
How would you ask about CAM feature 3 (1)?
Is the patient’s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
How would you ask about CAM feature 4 (5)?
Consider the following terms:
- alert [normal]
- vigilant [hyperalert]
- lethargic [drowsy, easily aroused]
- stupor [difficult to arouse]
- coma [unarousable])
What are the 1st line investigations for delirium (5)?
- Confusion bloods
- FBC
- CRP
- U&Es
- LFTs
- TFTs
- Calcium
- B12 and folate
- Glucose - Urinalysis
- Chest X-ray
- ECG
- Wound swab, sputum culture if ind
What are the 2nd line investigations for delirium (7)?
- Specific cultures e.g. sputum, blood, CSF, if suspect e.g. sepsis
- ABG
- CT head
- MRH head
- LP
- Electroencephalogram
- Wound swab, sputum culture if indicated
What are the 4 main elements of managing delirium?
- Identify and treat the underlying cause
- Management of the symptoms of delirium
- Prevention of complications
- Patient and relative explanations
In the management of delirium, what are the main things you do to regarding treatment of the underlying cause (3)?
- Removal of offending medications (many drugs have low level anticholinergic activity, stop as many as are not immediately indicated)
- Treatment of infection
- Correction of hypoxia and metabolic derangements
In the management of delirium, how do you manage the symptoms of delirium (11)?
- Nurse in an optimal environment (quiet, light, appropriate numbers of staff, orientation cues).
- Promote orientation (clocks, orientation boards, mealtimes)
- Analgesia as required but avoid opiates if possible
- Maintain hydration and nutrition
- Good sleep hygiene (i.e. avoid sleep during the day, avoid stimulants and too much fluid before bed)
- Regular clinical updates with relatives and encourage them to be in attendance
- Consider 1 to 1 nursing care
- Use the least restrictive option with wandering patients
- Avoid agreeing with rambling speech by tactfully disagreeing - changing the subject while acknowledging feelings but ignoring content
- Keep the use of sedative drugs to a minimum
- Reassurance and keep calm
What are 9 complications of delirium?
- Falls +/- injury
- Pressure ulcers
- Nosocomial infections
- Incontinence
- Medication side effects
- Malnutrition
- Functional decline
- PTSD
- Death
In the management of delirium, how do you reduce complications (5)?
- Thorough medical assessment and treatment
- An MDT approach, ‘rehabilitation nursing’ (get out of bed, get dressed, purposeful activity)
- Good continence care
- Attention to pressure ulcer prevention, early detection and management.
- Attention to hydration, nutrition and pain
In the management of delirium, how do you deal with relatives (4)?
- Explain to relatives, as seeing a loved one delirious can be distressing for families
- Involve families in early discussions and stress the importance of their input in helping to manage the condition.
- Familiar faces are reassuring: allow open visiting and encourage families to help with sitting with the patient.
- Encourage them to use orientation tactics, bring in familiar objects from home and help at meal times
What are 2 functions for use of sedative drugs?
- For the rapid tranquilisation of an agitated patient when there is an immediate risk of harm or danger (most hospitals have guidance on the drug choice and dose)
- For short term control of distress
When using a sedative drug, what are 3 guidelines you should follow?
- Use one drug only
- Start at the lowest dose possible
- Consider increasing increments after 2 hours
What 2 drugs can be used for sedatives?
What are side effects of the 1st line sedative that contraindicates it?
- Haloperidol -> 1st line
- Lorazepam
Haloperidol contraindicated in Parkinson’s or LBD. Monitor closely for any side effects EPSE, increased risk of falls, etc.
What is the prognosis of delirium? What % of delirium persists at: 1. 2 weeks 2. 1 month 3. 3 months 4. Never recover
- 40% persist at two weeks
- 33% at a month
- 25% at 3 months
- approx 20% never recover
What are causes of delirium?
Mneumonic - delirium
Drugs – withdrawal, toxicity, new / Dehydration
Electrolyte imbalance
Level of pain
Infection / Inflammation (e.g. post op)
Respiratory failure (hypoxia, hypercapnia)
Impaction of faeces
Urinary retention
Metabolic (liver, renal, hypoglycaemia) / Myocardial
infarction
