Neuro - Delerium

Question 1

Define delirium

Answer 1

An acute alteration in conciousness and awareness that fluctuates over time

Features:	Disorded thinking	Reduced attention	Abnormal sleep/wake	Abnormal psychomotor activity	Abdnormal perceptions	Changed emotional behaviour

Question 2

DSM criteria

Answer 2

Four criteria: Disturbed conciousness with reduced focus, or cannot sustain attention Change in cognition (memory loss) or perceptual disturbance Happens over a short period of time and fluctuates throughout day Evidence that these changes occur physiological consequences of a medical condition OR the delirium has more than one aetiology

Question 3

ICD 10 criteria

Answer 3

1) clouding of conciousness —> reduced awareness of environment, change in attention2) disturbed cognition —> impaired reall and recent memory (remote memory intact) Disorientated in time place person3) Psychomotor disturbance (hypo to hyperactice, startled ++, increased reactions)4) Disturbed sleep-wake cycle —> insomnia, dreams and nightmares5) Rapid onset and fluctuant6) evidence from hix/O/E that systemic disease or cerebral disease is responsible

Question 4

Pathophysiology of delirium

Answer 4

Neurotransmitter imbalance Reduced Ach Increased dopamine INCREASED NEURONAL EXCITABILITYPossible cerebral microvascular dysfunction due to inflammatory mediators OR global failure of oxidative metabolism —> cerebral insufficiency

Question 5

Types of delierium

Answer 5

Hyper, hypo and mixedHyper - 1% Confused, agitated, combative, paranoidHypo 35% Inattention, stupour, withdrawn, ?Mistake for depressedMixed 64%

Question 6

Risk factors

Answer 6

Patient, Illness and iatrogenic

Patient	Age	Co-morbids	Pre-existing cognitive impairment/psych hx	Alcohol / substance misuse

Illness	High APACHE	Sepsis	Hypoxia	Metabolic impaired - acidosis, Na balance	Surgery (CPB!)

Iatrogenic Sleep wake cycle - environment, noise etc Sedatives - benzos Anticholinergic meds

Question 7

Consuequences of delirium

Answer 7

Short, medium and longShort term Adverse events - extubation, line pulledMedium Increased LOS in ICU/hopspital Increased MV Increased mortality (3x risk factor)Long PTSD Cognitive impairment

Question 8

Diagnosis/Screening methods

Answer 8

CAM-ICU (Confusion Assessment method)ICDSC (Intensive Care Delirium Screening Checklist)

Question 9

Reducing the risk

Answer 9

Use of bundles e.g. ABCDEAwake and breathing - sedation holds and SBT —> reduces sedation and MV needsChoice of sedative -> minimise use of benzosDelirium monitoring —> CAM-ICUEarly mobilisationEnvironmment - orientation etcGood sleep hygieneRemove invasive devices once not needed

Question 10

Management

Answer 10

Non-pharmacology and pharmaNon - sedation holds, SBTs, re-orientation, family visits etcPharm Antipysch - haloperidol, olanzepine, quetiapine, rispiridone Dexmedotomidine (a2 agonist)

Question 11

Evidence for Dex Med

Answer 11

DahLIA trial - dexmed vs placebo Reduced vent free days at day 7 Non significant reduction is LOS UNDERPOWEREDMidex/prodex Double blind RCT Dex was non-inferior to midaz or propofol Duration of sedation shorter compared to midaz (but not propofol)

Question 12

CAM-ICU - describe

Answer 12

1) acute onset or fluctuation Have they changed from baseline. 2) inattention test - letters SAVEAHAART3) Altered level of concious —> RASS4) Disoragnisned thinking (stones in water)NEED 1 plus 2 and 3 OR 4

Question 13

ICDSC

Answer 13

Checklist done by nursing staff obvserving behaviours through the dayAltered level of concious RASS etcInattentionDisorientatedHallucinationPsychomotor agitationMoodSleep disturbedFluctuation