Lecture 12 Delirium

Question 1

The Confusion Assessment Method for the ICU (CAM-ICU)

Answer 1

1. Evidence-based assessment tool for clinical delirium; should be used for all older adults admitted to an ICU.
2. Yes/no question format in the areas of: Acute onset or fluctuating course; inattention; disorganized thinking; and altered level of consciousness.
3. Can be used with nonspeaking, mechanically ventilated patients; can be adapted for use with patients with visual and hearing disturbances.

Question 2

Older adults may have an atypical presentation of illness, encompassing _

Answer 2

1. Vague presentation.
2. Altered presentation.
3. No presentation.

Question 3

Early indicators of underlying disease in the older adult population

Answer 3

1. Change in mental status.
2. Falls.
3. Dehydration.
4. Decrease in appetite (this is also a normal age-related change).
5. Pain.
6. Loss of function.
7. Dizziness.
8. Incontinence.

Question 4

The most effective way to monitor for changes in health status is _

Answer 4

Observing changes from a previously established activity baseline.

Question 5

A primary cause of change in mental status, particularly confusion, in older adults is _

Answer 5

Drug toxicity.

Question 6

Until proven otherwise, new falls should always be seen as _

Answer 6

A symptom of illness.

Question 7

The decreased muscle mass of older adults predisposes them to _

Answer 7

Dehydration.

Question 8

Older adults experiencing heart failure and early-onset pneumonia often present with _

Answer 8

A decreased appetite or early satiety.

Question 9

In a patient with dementia, resisting a caregiver’s attempts at repositioning most likely indicates _

Answer 9

Pain.

Question 10

The best pain scale to use with older adults experiencing chronic pain is _

Answer 10

The Wong-Baker FACES Pain Scale.

Question 11

The most effective way to monitor function is to establish a baseline by _

Answer 11

Observing the patient as he performs his usual ADLs.

Question 12

Nursing assessment of a patient experiencing dizziness should always include _

Answer 12

1. Orthostatic blood pressures.
2. Most recent EKG.
3. Neurologic - gait and balance.

Question 13

Atypical presentation of a urinary tract infection classically presents in older adults with _

Answer 13

1. Cognitive changes - confusion.
2. Loss of appetite.
3. New-onset urinary incontinence.

Question 14

_ and _ are two typical signs of infection that may be absent in older adults with an atypical presentation.

Answer 14

Fever/chills and leukocytosis (elevated WBC count).

Question 15

Older adults with pneumonia may present with _

Answer 15

1. Increased respiratory rate.
2. Decreased appetite.
3. Decreased functional ability.

Question 16

_ is often overlooked in individuals with chronic dependent edema and vascular disease.

Answer 16

Cellulitis.

Question 17

RLQ pain with anorexia and elevated WBCs is likely to reflect _, which is often overlooked in older adults.

Answer 17

Appendicitis.

Question 18

The most common sign of acute MI in the older adult is _

Answer 18

Sudden onset of dyspnea.

Question 19

_ is a sign of worsening heart failure in the older adult.

Answer 19

Decreased appetite.

Question 20

Older adults with type 2 diabetes often present with _

Answer 20

Dehydration and confusion.

Question 21

_ is the early symptom of hypoglycemia.

Answer 21

Confusion.

Question 22

Mnemonic for common causes of delirium

Answer 22

D= Drugs
E= Elimination (urinary retention, constipation)
L= Liver and other organ failure
I= Infection
R= Respiratory - hypoxia
I= Injury - trauma, pain, stress
U= Unfamiliar environment
M= Metabolic imbalance (B12, folate)

Question 23

Inattention is a classic clinical manifestation of _

Answer 23

Delirium.

Question 24

Delirium is characterized by _

Answer 24

1. Acute onset and fluctuating course.
2. Inattention - core sign of delirium.
3. Disorganized thinking.
4. Rambling, incoherent speech.
5. Altered level of consciousness.
6. Perceptual disturbances - hallucinations (visual).
7. Disturbed sleep-wake cycles (increased agitation at night).
8. Psychomotor agitation or retardation.

Question 25

Subtypes of delirium

Answer 25

1. Hyperactive (20% of cases) - best prognosis.
2. Hypoactive (80% of cases).
3. Mixed (included in hypoactive) - worst prognosis.

Question 26

Among all hospitalized older adults who undergo surgery, _ will experience delirium.

Answer 26

56%

Question 27

Surgery for _ is most frequently associated with the onset of delirium in older adults.

Answer 27

Femoral neck fractures.

Question 28

The leading predisposing factor for the development of delirium in older adults is _

Answer 28

Unmanaged pain.

Question 29

An activating neurotransmitter that is believed to contribute to the development of delirium is _

Answer 29

Dopamine.

Question 30

Inadequate amounts of _ can lead to drug toxicity and thus precipitate delirium.

Answer 30

Albumin.

Question 31

Urinary catheters are considered physical restraints, and should only be used in cases of _

Answer 31

1. End stage of a terminal disease.
2. Renal monitoring on a short term basis.
3. Diversion due to a wound in the area.
4. Intra-operative and immediate post-operative phases.

Question 32

_ is a drug used to sedate surgical patients which increases blood-brain barrier permeability and may contribute to a cytokine imbalance in the CNS that can induce delirium.

Answer 32

Propofol.

Question 33

For delirium to be diagnosed using the CAM tool, the patient must exhibit _

Answer 33

1. Both acute onset/fluctuating course and inattention; and
2. Either disorganized thinking or altered level of consciousness.

Question 34

The medication of choice to treat delirium, especially when severe agitation and psychosis are present, is _

Answer 34

Haloperidol (Haldol).

Question 35

Use of benzodiazepines is avoided in the elderly, except in cases of _

Answer 35

Alcohol withdrawal.