Geriatrics Flashcards
Acute confusional state aka
delirium or acute organic brain syndrome
Delirium affects what % of the elderly admitted to hospital?
30%
Predisposing factors to delirium?
> 65yrs
Background of dementia
Signif injury eg. hip fracture
Frailty or multimorbidity
polypharmacy
Delirium= The precipitating events are often multifactorial and may include….
infection: particularly urinary tract infections
metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
change of environment
any significant cardiovascular, respiratory, neurological or endocrine condition
severe pain
alcohol withdrawal
constipation
Features of delirium?
a wide variety of presentations…
memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention
Mx of delirium?
treatment of the underlying cause
modification of the environment
haloperidol 0.5 mg as the first-line sedative or olanzapine
Mx of delirium in pt with parkinsons?
antipsychotics can often worsen Parkinsonian symptoms
careful reduction of the Parkinson medication may be helpful
if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred
1st line sedative Mx for delirium?
0.5mg haloperidol
Delirium (sometimes called ‘acute confusional state’) is….
an acute, fluctuating encephalopathic syndrome of inattention, impaired level of consciousness, and disturbed cognition
Delirium can be classified into subtypes based on symptoms= list the types?
Hyperactive delirium
Hypoactive delirium
Mixed delirium
Hyperactive delirium?
can present with inappropriate behaviour, hallucinations, or agitation.
Hypoactive delirium?
can present with inappropriate behaviour, hallucinations, or agitation.
Mixed delirium?
presents with signs and symptoms of both hyperactive and hypoactive subtypes.
Delirium typically occurs in people with …
predisposing factor (such as advanced age or multiple comorbidities) when new precipitating factors (such as some medications or infection) are added.
A diagnosis of delirium can be made using…
an assessment tool such as the short Confusion Assessment Method (short-CAM) or the criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are met.
Most people with delirium require..
admission to hospital for urgent assessment and multidisciplinary management.
Management of delirium in primary care may be appropriate if all of the following apply…
The benefits of management in primary care outweigh the benefits of hospital admission, or the person is clinically well enough to stay at home.
The symptoms of delirium are not harmful to the person or others, and can be managed safely in primary care.
The cause of delirium is known and treatable.
Constant supervision and care are available.
Close clinical follow up can be arranged.
Management of delirium in primary care involves…
Correcting any precipitating factors (for example infection or constipation).
Optimizing treatment of comorbidities such as heart failure.
Giving advice to carers and families on: reorientation strategies, mobilizing safely, normalizing the person’s sleep-wake cycle.
Use of verbal and non-verbal de-escalation techniques to deal with challenging behaviour (such as aggression, agitation, or shouting).
Pharmacological treatment such as antipsychotics or benzodiazepines should be avoided, if possible.
Giving verbal and written information on delirium to the person and their carer.
Reviewing the person’s response to treatment within 24 hours and regularly thereafter until symptoms have resolved, and adjusting treatment if appropriate.
Arranging admission or seeking advice from an elderly care physician or psychiatrist (as appropriate) if the person fails to improve or deteriorates.
Delirium= If admission is not appropriate, advice should be sought from an elderly care physician or psychiatrist when?
There is doubt about the diagnosis.
The person has severe delirium.
Detention under the Mental Health Act (1983, amended 2007) is being considered.
Further investigations not available in primary care are needed.
The person does not respond to initial treatment in primary care.
The CAM criteria for delirium?
Confusion that has developed suddenly and fluctuates, and
Inattention — ask if the person is easily distracted or has difficulty in focusing attention, and either
Disorganised thinking — ask if the person’s thinking is disorganised, incoherent, illogical, or unpredictable (for example they have an unclear flow of ideas, change subject unpredictably, or have rambling or irrelevant conversation), or
Altered level of consciousness — ask about changes in level of consciousness from alertness to: lethargy (drowsy, easily aroused); stupor (difficult to arouse); comatose (unable to be aroused); or hypervigilant (hyper-alert).
The DSM-5 criteria for delirium?
A. Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during a day.
C. An additional disturbance in cognition (such as memory deficit, disorientation, language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by a pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication, or withdrawal (due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple aetiologies.
The 4A’s test (4AT) for delirium?
This is a short, four-item tool designed for use in clinical practice.
The four items are alertness, cognition (a short test of orientation), attention (recitation of the months in backwards order), and the presence of acute change or fluctuating course.
Specialists such as elderly care psychiatrists, the challenging behaviour team, or elderly care physicians may suggest pharmacological measures as a last resort for severe agitation or psychosis if ….
Verbal and non-verbal de-escalation techniques are inappropriate or have failed, and
The person is a danger to themselves or others, and
The cause of delirium is known and being treated, and
The benefit outweighs the risk to the person, and
There is enough care in place for the person to be continually monitored.
Medication for dleirium?
Short-term (for 1 week or less) low-dose haloperidol
Antipsychotic drugs should be avoided, or used with caution in Parkinson’s disease or dementia with Lewy bodies