Old Age Psychiatry Flashcards
What is delirium?
Also known as ‘acute confusional state’
Acute (hr-d onset), fluctuating syndrome of disturbed:
Consciousness
Attention
Cognition
Perception
What is the ICD-10 criteria for the diagnosis of delirium?
Impairment of consciousness and attention Global disturbance in cognition Psychomotor disturbance Disturbance of sleep-wake cycle Emotional disturbances
Describe the illness course of delirium
Sudden onset
Fluctuating course
Gradual resolution: up to 6-months
Following effective treatment of underlying cause
List the three clinical presentations of delirium
Hyperactive delirium
Hypoactive delirium
Mixed delirium
Describe hyperactive delirium
Psychomotor agitation Increased arousal Inappropriate behaviour Hallucinations: commonly visual Delusions: commonly persecutory Restlessness and wandering are common
Describe hypoactive delirium
Psychomotor retardation Appear quiet or withdrawn Lethargy Reduced appetite Excess somnolence (drowsiness)
Describe mixed delirium
Combination of hyperactive and hypoactive delirium with varying presentation over time
Name three predisposing factors for delirium
Elderly or very young
Pre-existing dementia
Sensory impairment: eg. visual or hearing
Post-op (especially cardiac)
Alcohol abuse; benzodiazepine-dependent; poor nutrition
Serious and/or multiple illnesses; polypharmacy
Lack of stimulation
Provide five precipitating factors for delirium
Delrium is usually multifactorial
UTI; chest infections; infected pressure sore; sepsis
Hyperglycaemia; hypoglycaemia; electrolyte abnormalities
MI; heart failure; stroke; intracranial bleed
Thyroid dysfunction; PE; COPD exacervation
Urinary retention; constipation; malnutrition
Severe uncontrolled pain; major surgery
Medication changes; alcohol intoxication or withdrawal
eg. opiods; benzodiazepines; steroids
Hospital admission; emotional stress; sleep deprivation
Name five complications of delirium
High mortality (20% during admission, up to 50% at 1yr) Increased duration of stay Nosocomial infections Institutionalisation and/or re-admission Increased risk of: Dementia Falls Pressure sores Continence problems Functional impairment; distress for self/carers
What is the association between delirium and dementia?
Delirium causes neuronal death ➔ Independent cause (3x more likely) for dementia development and progression
Pre-existing dementia is a predisposing factor for delirium
Request three investigations for suspected delirium
Cognitive testing: 4AT; MoCA; Addenbrooke's Urinalysis Sputum culture; CXR FBC; CRP U+Es; calcium HbA1c TFTs Haematinics: eg. B12; folate EEG
What are the management principles for delirium
Identify and treat underlying causes
Environmental and supportive measures
Avoid sedation unless severely agitated or a risk
Regular clinical review and follow-up
Name four environmental and supportive measures in the management of delirium
Maintain hydration and nutrition Physical environment eg. Safe environment; good lighting; noise reduction; clocks and calendars; hearing and visual aids Human environment eg. Same staff; firm clear communication; routine; prevent transfer Control of distressing physical symptoms Avoid unnecessary procedures Promote healthy sleep patterns
Name three physical environmental factors for optimal management of delirium
Safe environment Adequate lighting Noise reduction Clocks and calendars If appropriate, hearing and visual aids
Name two human environmental factors for optimal management of delirium
Same group of staff Firm clear communication Routine Prevent transfer Education for those interacting with patient
Outline the managment of a person with delirium who is distressed or considered a risk to themselves or others?
Verbal and non-verbal de-escalation
Short-term haloperidol
Lowest clinically appropriate dose; titrate to symptoms
Use with caution or none if Parkinson’s or Lewy body
Differentiate dementia from delirium
Delirium has altered consciousness and attention
Dementia:
Gradual onset (months to years); progressive deterioration
Normal consciousness; perceptional disturbances occur later
Normal sleep-wake cycle
Delirium:
Acute onset (hours to weeks); fluctuating course
Impaired consciousness; perceptional disturbances common
Disrupted sleep-wake cycle
Disordered thinking, language impairment, inattention
Euphoric, fearful, depressed or angry
What physical examination should be performed in delirium?
ABC Conscious level with AVPU or GCS Vital signs - o2, pulse, BP, temp, capillary blood glucose Nutritional and hydration status CV exam Respiratory exam Abdominal exam - check for urinary retention and rectal exam for faecal impaction Neurological exam including speech
What are the differentials for delirium?
Dementia Mood disorders Late onset schizophrenia Dissociative disorders Hypothyroidism and hyperthyroidism
What is the general management of delirium?
Treat underlying cause
Stop any potential offending drugs, laxatives or catheter if needed
Reassurance and re-orientation
Provide appropriate environment, quiet, well-lit side room, reassurance, family or friend
Manage any disturbed or stress behaviour, low dose haloperidol or olanzapine
Avoid benzos unless delirium is due to alcohol withdrawal
What is paraphrenia?
Paranoid delusions with or without hallucinations, but without the deterioration of intellect or personality.
Patients remain well orientated to time and space.
