Dementia and Delirium overview Flashcards
key criteria for diagnosis of delirium?
(acute confusional state):
- disturbance of consciousness and impaired cognition which has developed suddenly
- fluctuating course of symptoms over day
- features can be directly attributed based on hx and exam/investig to an underlying general medical condition, drug intoxication or WD or combination.
DSM-IV: A to A=disturbed consciousness B=impaired cognition C=disturbance develops over short period D=direct result of general med condition, drug intoxication/WD/combination
mean prevalence of delirium?
20%
prevalence of delirium post NOF fracture?
up to 50%!
what is the risk of delirium in patients with dementia?
they are 5 times more likely to develop delirium
complications of delirium?
increased mortality
prolonged hospital stay-increased risk of VTE, pressure sores, infections
increased risk of complications-falls, incontinence, medication ADRs, malnutrition, functional decline
increased risk of dementia
institutionalisation
types of delirium?
hypoactive (40%)-lethargy, reduced motor function
hyperactive (25%)-increased activity, agitation, hallucinations, inappropriate behaviour
mixed (35%)-fluctuate between the 2 during the day
example of a tool available to diagnose delirium, following a cognitive assessment with AMT?
confusion assessment method (CAM): each pt must have 1 and 2, and either 3 or 4 for delirium diagnosis to be likely (out of the 4 domains):
1-acute onset of changes and fluctuations in course of mental status
2-inattention
3-disorganised thinking
4-altered level of consciousness
time course of delirium?
impaired consciousness and cognition have acute onset with development over 1-2days, but condition can take up to 3 mnths to resolve, and some people never get back to their baseline.
key components to delirium hx?
onset and course of confusion symptoms suggestive of underlying cause e.g. cough, dysuria sensory impairment previous episodes comorbidities and DH alcohol hx intellectual function and education SH-functional status, what is their baseline? who does their shopping, cooking, cleaning? COLLATERAL HISTORY
components to examining a pt with delirium?
assess conscious level-GCS, AVPU
cognition assessment-AMT-less than 8/10 abnormal, CAM, MMSE
search for underlying cause e.g. resp exam. identify infection source e.g. remove bandages.
urinary retention, faecal impaction
nutritional and fluid status
neurological status including speech
mental state exam
investigations you might consider in a pt with delirum?
Bloods: FBC?infection, U+Es, LFTs, CRP, blood glucose, TFTs, Ca2+ imaging-CXR, CT head-only if on ACs and head injury,or if any neurological abnormalities ECG urinalysis-MSU basic obs specific cultures EEG LP ABG
steps in the management of a pt with delirium?
treat underlying cause
manage symptoms
prevent complications
good communication with pt and relatives
pharm and non pharm measures
stop any offending drugs, correct metabolic disturbances
treat infection
nurse in appropriate environment
orientate pt
ensure good nutrition
encourage good sleep pattern
encourage relatives to visit
engage in activities
analgesia if required (prescribe regular if think pt won’t ask for it)
keep meds to a minimum, sedate only if absolutely necessary as pt danger to themselves or others-haloperidol (0.5-1.5mg), 1-2mgIM, 5max in 24hrs or lorazepam (0.5-2mg), 0.5-1IM, max 3mg/24hrs
least restrictive option in terms of the wandering pt
what do we want to avoid in pts with delirium?
ward transfers, especially at night urinary catheterisation sedation anticholinergics physical restraints constipation and urinary retention
