Older persons mental health Flashcards
Describe the acute assessment of person with delirium
A to E
History - patient’s baseline, current diagnoses, medication, vascular problems (vascular demntia)
AMTS (quick method for objective assessment of cogntiion) - Can be repeated to allow ongoing recognition of improvement/deterioration
Could also use ACE-3/MMSE for more formal screening tool
Collateral Hx: WHat is normal for the paitnet, how long they have been confused for, what is different
Differences between delirium and dementia?
Onset; Delirum = Abrupt
Dementia = Insidious (unless stroke or trauma)
Course: Delirium = fluctuates
Dementia = slow decline
Durations: Delirium = hours to weeks
Dementia = Months to years
Attention: Impaired in delirium, intact early on in dementia
Sleep wake disturbance in delirium, normal in dementia
Orientation: Impaired in delirium, intact in early dementia
Behaviour: Agitated, withdrawn or depressed in delirium; normal in early dementia
Speech: Incoherent or rapid/slowed in delirium, word finding problems in dementia
Thoughts: Disorganised in delirium, impoverished in dementia
Perceptions: Hallucinations/illusions in delirium, intact in early dementia
Examinations to perform in confused patients?
o Respiratory conditions, for example chest infection, pulmonary embolus, heart failure, or chronic obstructive pulmonary disease.
o Cardiovascular conditions, for example myocardial infarction and heart failure.
o Abdominal conditions, for example acute abdomen, constipation, faecal loading (carry out a rectal exam if possible if impaction is suspected), urinary retention, and urinary tract infection.
o Musculoskeletal conditions, for example hip fracture.
o Neurological conditions, for example stroke, subdural haematoma, epilepsy, encephalitis, or drug intoxication.
o Skin conditions, for example infection, pressure sores, or ulcers.
o Electrolyte imbalance such as dehydration, acute kidney injury, hypercalcaemia, or hyponatraemia.
o Endocrine and metabolic disorders such as cachexia, thiamine deficiency, or thyroid dysfunction.
o Sensory impairment, for example impacted ear wax, ill-fitting or non-functioning hearing aids, and spectacles.
o Pain — look for non-verbal signs of pain, particularly in people with communication difficulties.
Ix to perform in acute delirium patients?
o Urinalysis — to identify conditions such as infection or hyperglycaemia. Arrange a mid-stream urine (MSU) if urinalysis is abnormal
o Sputum culture — to identify chest infection.
o Full blood count — to identify infection or anaemia
o Folate and B12 — to identify vitamin deficiency.
o Urea and electrolytes — to identify acute kidney injury and electrolyte disturbance (such as hyponatraemia or hypokalaemia
o HbA1c — to identify hyperglycaemia
o Calcium — to identify hypercalcaemia or hypocalcaemia
Criteria used to confirm delirium?
DSM-IV criteria or short-CAM. CAM features:
o Confusion – sudden onset and fluctuates
o Inattention – easily distracted or difficulty focussing
o Disorganised thinking - disorganised, incoherent, illogical, or unpredictable (for example they have an unclear flow of ideas, change subject unpredictably, or have rambling or irrelevant conversation)
o Altered level of consciousness
Mx of delirium?
• Treat underlying cause
• Supportive Mx: consistent care team, reorientation (explaining where the person is, who they are, and what your role is), ensure paitent has vision and hearing aids and mobility aids
Encourage patient to be independent (washing, dressing, eating, toileting and other activities may still be possible with varying levels of encouragement.)
Environment: Access to a clock; familiar objects (photographs, use patient’s own clothes), involve family, friends, carers in the care of patient, control level of noise around patient, ensure adequate lighting
If distressed/ considered a risk to themselves or others – 1st use verbal and non-verbal techniques to de-escalate the situation
• If ineffective or inappropriate - consider giving short-term (usually for 1 week or less) haloperidol.
If benzos required - lorazepam
Measures to prevent delirium?
- Provide support by carers who are familiar to them
- Medication review
- Avoid moving the person unnecessarily and Keep their surroundings familiar
- Cognitive impairment: Make sure the person can see a clock and calendar; Talk to the person to help orientate them; Make sure any hearing aids and glasses are being worn and work well
- Dehydration/ constipation: Encourage person to drink; Support the person to avoid/ address constipation
- Infection: Look for signs of infection; Avoid using a catheter as far as possible
- Avoid disturbing the person during sleep periods
- Limited mobility: Encourage person to walk; provide support to do a range of active exercises
- Pain: Ensure pain in well-managed. Make sure to look for sugns of pain (esp. if LD or dementia (Abbey Pain Scale - pain assessment tool developed for use in demented nonverbal patients)
- Poor food intake: Make sure any dentures are clean, being worn and fit well
Features of hyper and hypoactive delirium?
Hyperactive delirium: Agitation Delusions Hallucinations Wandering Aggression
Hypoactive delirium: Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention
Factors that favour delirium over dementia?
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions
Define delirium
an acute, transient and reversible state of confusion, usually the result of other organic processes (infection, drugs, dehydration), the onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.
Hypoactive delirium vs depression
Delirium: Fluctuating course, acute onset, altered conciousness, marked inattention, underlying physical cause, disorientation, disorganised thinking, poor comprehesion
Causes of Delirium?
Constipation Hypoxia Infection Metabolic disturbance Pain Sleeplessness Prescriptions Hypothermia/pyrexia Organ dysfunction (renal/liver impairment) Nutrtion Environmental changes Drugs (over the counter, illicit, recreational, their partner/neighbour/pets’, alcohol and smoking)
Describe the confusion screen
Vital signs: blood pressure, heart rate, respiratory rate, oxygen saturation level, temperature and level of consciousness
CT head - stroke, bleed, SOL
Bloods:
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g. hypoglycaemia)
Blood cultures (e.g. sepsis)
CXR
Urine tests - Positive urine dip not enough to dx urinary sepsis - other signs: WCC↑/supra-pubic tenderness/dysuria/offensive urine/positive urine culture)
Delirium Mx post discharge?
Families/carers need to be aware that delirium can continue for a period of time after the cause has been treated.
Information should be given to those surrounding the patient on the management of any residual disorientation or inattention.
Follow-up is advisable.
