older - confusion - DELIRIUM/DEMENTIA Flashcards
what are the main problems of the elderly?
Delirium and dementia
what is delirium?
neurocognitive disorder of acute confusion characterized by impairments and FLUCTUATIONS in attention and awareness (reduced orientation to the environment),
as well as other cognitive disturbances (e.g., in memory, language,- Slurred speech and language difficulties, talking that doesn’t make sense or perception). Symptoms develop acutely and tend to fluctuate throughout the day
DELIRIUM IS REVERSIBLE
what is acute encephalopathy ?
A pathobiological process in the brain that:
Is diffuse (i.e., without an associated structural lesion)
Develops rapidly (i.e., within hours to days, but < 4 weeks)
Can manifest as delirium, stupor, or coma
Can be further specified according to the suspected underlying mechanism, e.g., acute toxic-metabolic encephalopathy
aetiology of delirium
Pediatric,
elderly (> 65 years), and hospitalized patients are particularly susceptible.
Typically secondary to:
1) Metabolic diseases
most common causes metabolic encephalopathy :
- Liver or kidney failure
- Diabetes mellitus (diabetic ketoacidosis)
- Hyperthyroidism or hypothyroidism
- Vitamin deficiencies (e.g., vitamin B12 deficiency, folic acid deficiency, thiamine deficiency)
- Electrolyte abnormalities
7) Infection such as UTIs (most common cause in elderly patients!!!), pneumonia, meningitis
8) Trauma (e.g., hip fracture, head injury)
9) CNS pathology (e.g., stroke, brain tumor)
10) Hypoxia (e.g., anemia, cardiac failure, COPD, pulmonary embolism)
11) Acute cardiovascular disease (MI, shock, vasculitis)
12) Drugs and toxins (also referred to as toxic encephalopathy)
Anticholinergics
Benzodiazepines, barbiturates
antidepressants
clinical features of delirium ?
acute (hours to days) alteration in the level of awareness and attention.
Other features may include: Disorganized thinking Illusions Hallucinations (mostly visual) Cognitive deficits (e.g., memory) Reversal of the sleep-wake cycle Emotional lability Agitation, combativeness
The severity of symptoms fluctuates throughout the day and worsens in the evening (termed sundowning).
Symptoms are reversible; their duration and severity depend on the underlying illness.
Z
Delirium is commonly described based on the type of alteration that is seen:
mixed delirium : psychomotor activity fluctuates or stays at baseline
= general pop
hypoactive delirium psychomotor activity is decreased so there is lethargy slowness excessive sleeping inattention = elderly
hyperactive delirium psychomotor activity is increased so there is agitation delusions hallucinations = seen in delirium with substance abuse or substance withdrawl
diagnosis with delirium ?
1) Metabolic diseases
most common causes metabolic encephalopathy :
- LIVER OR KIDNEY FAILURE
UE
LFT
- DIABETES MELLITUS (DIABETIC KETOACIDOSIS) glucose <33.3mmol/l bicarbonate <18mmol/l elevated anions gap Urinalysis : Moderate-large urine ketones (ketonuria) Glucosuria Serum β-hydroxybutyrate abg : PH
-HYPERTHYROIDISM OR HYPOTHYROIDISM
TSH , T4
(carbimazole and propylthiouracil)
-Vitamin deficiencies (e.g., vitamin B12 deficiency, folic acid deficiency, thiamine deficiency)
- adrenal infucfency
random cortisol levels - Electrolyte abnormalities
BMP
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7) Infection such as UTIs (most common cause in elderly patients!!!), pneumonia, meningitis
urine culture a urine dipstick test and/or microscopy Pyuria: presence of white blood cells (WBCs) in the urine Positive leukocyte esterase Urine culture
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8) Trauma (e.g., hip fracture, head injury)
CT of head
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9) CNS pathology (e.g., stroke, brain tumor)
CT of head
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10) Hypoxia (e.g., anemia, cardiac failure, COPD, pulmonary embolism)
FBC - hemoglobin
echo -
COPD - spirometry
pulmonary embolism - D - dimer test
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11) Acute cardiovascular disease (MI, shock, vasculitis)
ECG
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12) Drugs and toxins (also referred to as toxic encephalopathy)
Anticholinergics
Benzodiazepines, barbiturates
antidepressants
blood toxicology reports
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magnesium
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in diagnosis what are the congnitive assesments we have to do ?
AMT - asses congintion
detailed assesment through
(age, DOB, house address, current year) = max 10
e 0–3 is suggestive of severe impairment; 4–7 moderate impairment; 8 and above is
suggestive of normal cognitive function.
what is the management in confusion?
A-E
D - AVPU and GCS
======= assess risk factor age >65 severe illness current hip fracture evidence of head trauma
============= confusion SCREEN blood tests : FBC - infection anaemia UE - hypo or hypernatremia LFT - liver failure with secondary encephalopathy coagulation INR - intracranial bleeding TFT - hypothyroidism calcium - hypercalcemia B12 and folate haemetics -deficieny glucose blood culture ===== AMT
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urinalysis
UTI very common cause of delirium in elderly
urine dipstick - leukocyte esterase and nitrites
= microscopy
Pyuria: presence of white blood cells (WBCs) in the urine
urine culture
supra pubic tenderness , dyuria , offensive urine , p
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imaging
CT and chest x ray
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defintive management
consistent nursing and medical team with gentle reorientation and regular instruction of yourself and your role with clear and concise communication
atleast three times daily hospital staff or family should reorient the patient to time place and person
ensure patient has access to aids - glasses , hearing aids , walking sticks
enable patient to do what they can which is washings , dressing , eating , toileting etc
ENVIRONMENTAL ADPATATION ensure access to close familiar objects - photographs , patients own clothes involve family and friends in care control level of noise ensure lighting is adequate
MEDICATION
sedation can make delirium worst - only reserved when they pose a risk to themselves
aim to keep the patient safe and least restrictive method
antipsychotics:
HALOPERIDOL - oral IV or IM - usually first line
second line -benzodiazepines - lorazepam
reserved for alcohol or benzodiazepine withdrawl
Patients with delirium which are agitated and aggressive - should initially be managed with nonpharmacoliogcal stratgies = such as reorientation , reassurance
rrange family member to remain at patient side
identify and treat reversibel causes of agitation - dehydration , hunger , pain , hypoxia
AVOID physical restraints as much as possible
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post discharge
familes and carers given information that delirium has occured and mikght occur ven after the cause has been eradicated
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PREVENTION
avoid drugs known the precipitate delirium - opiates and benzodiazepines
anticholinergics
avoid restraints if possible
reorientate the patient regurarly - keep clock or calender near the patient
provide cisualand hearing aids
at night reduce the amount of npise and medication administration
UNINTERRUPTED SLEEP - important for prevention and management
REGULAR visus from family and friends
identify patients at high risk
asses other factors which may include or exacerbate delirium -pain control drugs
employ supportive and environmental management
falls risk assessment
for maintaining fever and pain control in delirium what is avoided ?
opoid medications is avoided
and preferable controlled with non opoid drugs
what are the complication of delirium ?
decubitis ulcers
aspiration of food and fluid
falls and injury
when is the contraindication of antipsychotics ?
in patients with alcohol withdrawl or benzodiazpine withdrawl - due to high risk of seizures
and patient at high risk of QTc prolongation - due to risk of torsades de pointes
what are the complication of these benzodiazepime and haloperidol
can increase falls
benzodiazepine are delirogenic themselves so do not treat patients with them unless through indiucations
what is the differential diagnosis with delirium ?
MOST confused with DEMENTIA
what is the difference between delirium and dementia ?
ONSET
DeliRium - sudden
DeMentia - insidious
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COURSE
DR - rapid and fluctuating (hours to days )
DM - slowly progressive - months to years
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LEVEL OF CONCIOUSNESS
DR - decrease
DM - intact
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ATTENTION
DR - impaired (fluctuating)
DM - usually alert
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MEMORY
DR- recent memory loss
DM - recent athen REMOTE memory loss
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HALLUCINATIONS
DR - present - VISUAL and tactile
DM - present in advanced cases
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PSYCHOMOTOR ACTIVITY
DR - increased or decreased
DM - normal
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EEG
DR- usuallyabnormal
DM - usualy normal
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REVERSIBILITY
DR- reversible
DM - irreversible
