Neurology Flashcards
Cognitive impairment
Difficulty with memory, thinking, concentration, and ability to read and write
Delirium
- Acute confusional state
- State of an alteration of consciousness with reduced ability to focus, sustain or shift attention, causing cognitive or perceptual disturbance + ANS hyperactivity
- Develops over short period of time (hrs-days) and fluctuated during the day
- Reversible
Causes of delirium
D = drugs (withdrawal/toxicity), OR dehydration
E = electrolyte imbalance, environment, enforced bedrest
L = level of pain
I = infection/inflammation (post surgery)
R = respiratory failure (hypoxia/hypercapnia)
I = impaction of faeces, imobility
U = urinary retention, IDC
M = metabolic disorder (LF, hypoglycaemia), MI, malnutrition
S = surgery, sensory impairment, sepsis, sleep deprivation
Pathophysiology of delirium
Direct brain insult (e.g. hypoxia, hypoglycaemia, electrolyte imbalance)
* Disrupts NT systems causing cerebral dysfunction (reduced cholinergic function, increased dopamine, NA, glutamate)
* Injury also causes increased ICP, altered consciousness and delirium
Stress response
* Overstimulation of normally adaptive systemic and CNS responses to stress, trauma, anxiety, injury etc that affects cognition, mood, perception
Forms
1. exaggerated response to normal levels of pro-inflammatory mediators (cytokines, PGs) that affect NTs
2. Abnormally intense stress response & impaired HPA axis –> **high cortisol **–> disturbed circadian rhythm
* This disrupts neural networks in the reticular activating system (consciousness, wakefullness) of the upper brain stem, that projects into the cerebral cortex and limbic areas
Sickness behaviour
Adaptive changes in an individual during a period of illness used to conserve energy and minimise further insult (fatigue, anhedonia, reduced appetite)
Features of delirium
Acute or new deterioration
- Disorientation
- Memory impairment
- Inattention
- Disorganised thinking
- Hallucinations
- Motor abnormalities
- Alt sleep-wake cycle
- Alt consciousness
4
Types of delirium
Hypoactive
* Most common but often missed, pt is withdrawn, drousy, quiet
Hyperactive
* Most recognised, pt is loud, restless, agitated, heightened arousal
Mixed
* Fluctuates throughout the day
Terminal
* Agitated delirium in last few days of life
Delirium cognitive assessment & types
- Determine underlying cause
- Cognitive screening (AMT4 & single question in delirium (SQiD) for pts who
* >65 (>45 ATSI), severe illness, risk of death, hip fracture, cognitive impairment
AMT4: age, DOB, year, hospital
SQiD: (family member) “has pt become more confused, sleepy or drowsy lately?”
* If >4 or SQiD+ –> AMT10 & CAM (confusion assessment method)
If AMT <8 = inform shift coordinator, organise CAM
If AMT >8 = monitor pt for changes in thinking and behaviour
CAM (confusion assessment method) = acute or fluctuating changes, inattention, ALOC, disorganised thinking
Routine specific assessments in suspected or confirmed delirium
- Urinalysis - assess for UTI
- BGL - assess for hypoglycaemia
- O2 sat - for hypoxia
- PaO2 - hypoxaemia
- U&E - renal dysfunction & electrolyte imbalance
- (respiratory symptoms) Sputum sample and chest x-ray - pulmonary infection or disorder causing hypoxia
- RBC - low Hb, high WCC
Nursing management for delirium
First identify cause to guide management
- vitals 4 hrly, RBC, FNO
- Monitor postural HoTN = BD lying and standing BP (benzo/antipsych lower BP)
- FRAMP
- Monitor for PI, nutrition and hydration esp in hypoactive
- Ensure bladder isnt full, correct continence, regular UTI screening
- Protect invasive lines, remove ASAP
- Reduce stress (orientate, personal items in reach, family engagement)
Health promotion in delirium
- determine personal information that may calm and orient pt, encourage family to bring in belongings
- Encourage mobility and independence in ADLs, liase with PT and OT
- Communication aids (liase with SP)
- FRAMP = minimise risks
- Prioritise non-pharm methods
- Avoid bed rails
Discharge planning in delirium
- Involve the pt and carer in the plan
- Liase with multidisciplinary team including consultant liaison psychiatry and social work
- Assess for services required on discharge
- Provide information for services, facilities, and delirium patient information leaflet
Prevention of delirium
- Promote sleep quality and avoid sleep disturbance
- Limit polypharmacy & unecessary use of opioids, benzo and antihistamines
- Orient person to PPT (clock, calender, conservations, activites)
- Hydration
- Mobility
- Monitor for UTI, avoid unecessary catheterisation
- Support nutrition
- Assess for verbal and non verbal signs of pain
Serenace
Haloperidol
Indication, drug class, mechanism of action, effect, route, s/e
- Antipsychotic (oral, IV) used for acute confusion, hallucinations, delusions in delirium, schizophrenia and acute alcoholism
- High affinity dopamine antagonist that blocks the postsynaptic dopamine transmission
- Increased dopamine turnover (reduced concentration), reduced symptoms
- S/E: HoTN, tachycardia, dystonia, drowsiness
Largactil
Chlorpromazine
Indication, drug class, mechanism of action, effect, route, s/e
- Phenothiazine antipsychotic (oral) for short term management of agitation and behavioural disturbances in delirium and dementia
- D2 receptor antagonist, inhibiting dopamine transmission and alleviating symptoms (not fully understood)
- S/E: post HoTN, ECG changes, drowsiness, dry mouth, dystonia (anticholinergic effects)
