Geriatrics: delerium Flashcards
What is delerium?
○ Disturbed consciousness - Hypoactive/ hyperactive/ mixed ○ Change in cognition - Memory/ perceptual/ language/ illusions/ hallucinations ○ Acute onset and fluctuant
What are the common features of delerium?
- Disturbance of sleep
- Disturbed psychomotor behaviour- delirium affects your physical function
- Emotional disturbance
What precipitates delerium?
□ Infection (but not always a UTI!) □ Dehydration □ Biochemical disturbance □ Pain □ Drugs □ Constipation/Urinary □ Hypoxia □ Alcohol/drug withdrawal □ Sleep disturbance □ Brain injury ® Stroke/tumour/bleed etc □ Changes in environment □ Sometimes no idea and often multiple triggers
Why is delerium important?
□ More likely to die
□ More likely to stay in hospital longer
□ More likely to be discharged to a nursing home
□ More likely to develop infections etc. from the hospital
□ More likely to go on to develop dementia
□ It is very distressing for the patient
How is delerium diagnosed?
□ The 4AT ® Should be used to diagnose all delirium patients over the age of 65 ® Alertness ® Amt-4 ◊ Location ◊ Age ◊ Date of birth ◊ Year current ® Attention ◊ > Months correct going backwards ® Acute change
What should be done when delerium is diagnosed?
□ Treat the cause ® Full history and exam (incl. neuro) ® TIME bundle
□ Explain the diagnosis
What pharmacological measures should be taken in delerium?
® Remember DRUGS ARE BAD (mostly….) ® STOP BAD DRUGS ◊ Anticholinergics ◊ Sedatives ® Drug treatment of delirium usually not necessary ® No evidence it improves outcomes ◊ 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 (generally given before things escalate)
- This should be a consultant/ registrar decision
What non-pharmacological measures should be taken in delerium?
® 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 percentage of delerium is preventable?
30%
What is the trajectory of delerium?
□ Usually settles with management of underlying causes
□ Increasingly recognises that a lot of people don’t get back to previous level
□ May unmask undiagnosed cognitive impairment
□ More likely to devlop dementia
□ Risk factor for further episodes of delerium/dementia/frailty syndromes so remember to record and communicate diagnosis and organise follow up
What is dementia?
□ Acquired decline in memory and other cognitive functions in an alert person sufficiently severe to cause functional impairment and present for more than 6 months
® i.e. forgetting to take tablets ® Unable to use phone ® Difficulty washing/dressing □ Slow, insidious onset □ Loss of recent memory first
□ Progressive functional decline
What types of dementia are there?
- Alzheimer’s
- Vascular dementia
- Mixed alzheimer’s/ vascular dementia
- Dementia with Lewy bodies
- “Reversable” causes
- Fronto-temporal dementia
What is vascular dementia?
® Classically step-wise deterioration
® Executive dysfunction may predominate rather than memory impairment ® Associated with gait problems often ® Often have known vascular risk factors ◊ type II DM, AF, IHD, PVD
What is dementia with Lewy bodies?
® May have parkinsonism ® Often very fluctuant ® Hallucinations common ® Falls common ® Probably underdiagnosed
What is fronto-temporal dementia?
® Onset often at earlier age ® Early symptoms different from other types of dementia ◊ Behavioural change ◊ Language difficulties ◊ Memory early on often not affected
® Usually lack insight into difficulties
