Recognising and Managing Acute Confusional State Flashcards

1
Q

What is delirium?

A
  • An episode of acute confusion.
    • Onset usually over hours/days.
  • Delirium is a clinical syndrome which has disturbed:
    • Attention / consciousness
    • Cognitive function
    • Perception
  • Fluctuates
  • Due to underlying causes.
  • Can be hyperactive or hypoactive.
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2
Q

Describe hyperactive delirium.

A
  • Causes the patient to experience:
    • Agitation
    • Restlessness
    • Aggression
    • Loss of concentration
    • Confusion
  • May have hallucinations / delusions
  • Can be difficult to manage
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3
Q

Describe hypoactive delirium.

A
  • Hypoactive delirium causes:
    • Slowing down
    • Sleepiness/lethargy
    • Reduction of consciousness
    • Reduced speech or interaction
  • Higher mortality / poor prognosis
  • Much harder to spot - is often just thought to be lathargia or illness.
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4
Q

Describe mixed delirium.

A

A fluctuation between hyperactive and hypoactive delirium. A patient can swing from one to the other several times per day.

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5
Q

Compare and contrast delirium and dementia.

A

Delirium

Dementia

Sudden onset

Gradual onset

Fluctuates

Does not usually fluctuate

Consciousness: attention reduced

Consciousness: unchanged

Perception: hallucinations common

Perception: hallucinations usually a late feature

Speech: can be incoherent / slow / rapid

Speech: repetitive

Usually reversible

Usually not reversible

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6
Q

Which patients are likely to develop delirium?

A
  • Anyone with a severe enough insult (regardless of age).
  • Very common in ITU.
  • Vulnerable and frail people develop delirium with a much smaller insult - less physiological reserve.
  • Common in people with dementia - if a sudden worsening, screen for an underlying cause.
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7
Q

What are the risk factors for delirium?

A
  • Age >65
  • Background cognitive impairment or dementia.
  • Surgery, especially hip fracture - most people who have surgery for hip fracture are older and frail so it is probably the demographic which makes delirium more probable than the surgery itself.
  • Comorbidities.
  • Polypharmacy - 4+ medications increases risk.
  • Sensory impairment.
  • Functional Impairment - problems walking, needing help to go to the toilet.
  • Sleep disturbance.
  • Hospital admission.
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8
Q

Describe the main changes in the body associated with ageing.

A
  • Brain volume decreases by 5% per decade after 40.
  • Vascular changes - up to 20% less blood flow.
  • Reduced neurotransmitters (dopamine reduces by 10% per decade in adulthood).
  • Kidney and liver function - unable to clear drugs.
  • Decreased muscle mass, total body water and increased body fat - this changes how drugs are distributed through the body and this could potentially cause delirium.
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9
Q

Describe frailty.

A
  • Health state related to the ageing process in which multiple body systems gradually lose their in-built biological reserves.
  • People lose their ability to compensate when they are medically challenged.
  • Minor illnesses / insults can cause delirium and falls.
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10
Q

What are the effects of delirium? Why is it important?

A
  • Increased length of stay in hospital (21 vs. 9 days).
  • Increased risk of dying - in hospital (11% vs. 6%) and up to 1 year later (27% vs. 15%).
  • Increased risk of dementia.
  • Increased risk of falls, pressure sores.
  • More likely to go into 24 hour care (47% vs. 18% at 1 month).
  • Can be very frightening for patient and family.
  • Risk of death rises rapidly if not identified - increases by 11% with every 48 hour delay in diagnosis.
  • If identified adn communicated appropriately can be followed-up and screened for dementia.
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11
Q

Describe the pathophysiology of delirium.

A
  • Mechanisms are not fully understood - hypothesis based on animal models.
  • Changes to blood-brain barrier permeability; things which normally stay in peripheral circulation can enter the brain.
  • Cerebral hemispheres or arousal mechanisms of the thalamus and brain stem reticular formation become impaired.
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12
Q

Describe the pathophysiological mechanism of delirium.

A
  • Increased cortisol / stress
  • Increased cytokines (TNFα, IL1) / inflammation
  • Increased dopamine
  • Increased serotonin - stimulates the cortex.
  • Increased GABA
  • Decreased acetylcholine transmission (extremely important in cognition)
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13
Q

What is the function of the reticular activating system?

A
  • Network in the brain stem.
  • Responsible for:
    • Arousal
    • Sleep
    • Pain
    • Muscle tone
  • Ascending fibres arouse and activate the cerebral cortex.
  • Controls levels of consciousness.
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14
Q

Describe the process of identifying delirium.

A
  • Full history - obtain collateral history.
  • Key factors are acute onset, fluctuation, decreased attention.
  • Review medication.
  • Vital signs (NEWS scoring).
  • Physical and neurological examination for signs of infection, dehydration, neurological changes.
  • Consider capacity.
  • Consider in any confused older person and don’t assume they have dementia (collaborative history).
  • Look for plucking of bed clothes and air (carphology and floccillation).
  • Use a screening tool.
  • Up to 50% of cases missed by medical professionals.
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15
Q

What are the screening tools used in the identification of delirium?

A
  • SQiD - fo you think your relative has ben more confused recently?
  • CAM - confusion assessment method.
  • 4AT - recommended by Scottish Delirium Association.
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16
Q

Describe the confusion assessment method (CAM).

A

Consider the diagnosis of delirium and if 1 and 2, AND either 3a or 3b is present:

  1. Acute onset? Yes / no
  2. Inattention? Yes / no
  3. (a) Disorganised? (b) Altered consciousness? Yes / no
17
Q

Describe the 4AT.

A
  1. Alertness
    • Normal = 0
    • Mild sleepiness for <10 seconds on waking = 0
    • Clearly abnormal = 4
  2. AMT 4
    • Age, DOB, place, current year?
    • No mistakes = 0
    • 1 mistake = 1
    • ≥2 mistakes = 2
  3. Attention
    • Ask patient to recite the months of the year backwards starting at December.
    • Achieves ≥7 correctly = 0
    • Starts but scores <7 months / refuses to start = 1
    • Untestable (cannot start because too unwell, drowsy, inattentive) = 2
  4. Acute change
    • Evidence of significant change or fluctuation in:
      • Alertness
      • Cognition
      • Other mental function (hallucinations, paranoia) arising over the last 2 weeks and still evident in the last 24 hours.
    • No = 0
    • Yes = 4
18
Q

Describe the scoring of the 4AT.

A
  • Total between 0 and 12
  • ≥4 = possible delirium
  • 1-3 = possible cognitive impairment
  • 0 = delirium or significant cognitive impairment unlikely
19
Q

What are the precipitating causes of delirium?

A
  • Intracranial - infarction / bleed / infection / post-ictal / medications.
  • Extracranial - infection, metabolic, hypoxia, stress response, anaesthesia and surgery, any severe illness, pain.
  • Environmental / iatrogenic - emotional distress, sleep deprivation, change in environment, sensory impairment, catheters, drips, urinary retention, constipation.
20
Q

What is the delirium time bundle?

A
  1. Think, exclude and treat possible triggers.
  2. Investigate and intervene to correct underlying causes.
  3. Management plan.
  4. Engage and explore
21
Q

Describe the ‘T’ in the delirium time bundle.

A
  • Think, exclude and treat possible triggers.
  • NEWS/FEWS - think of the sepsis 6.
  • Blood glucose.
  • Medication history.
  • Pain review (Abbey pain scale).
  • Assess for urinary retention.
  • Assess for constipation.
22
Q

List the possible trigger medications for a delirium (starting or stopping).

A
  • Opiates (morphine, codeine, tramadol)
  • Anticholinergics (e.g. for bladder symptoms, pain killers)
  • Benzodiazepines (diazepam, nitrazepam)
  • Drugs used in Parkinsons
  • Antipsychotics
  • Antiepileptics
  • Antihistamines
  • Antihypertensives (if BP is too low or for low Na2+
23
Q

Describe the ‘I’ in the delirium time bundle.

A
  • Investigate and intervene to correct the underlying cause.
  • Assess hydration and start fluid balance chart.
  • Blood (FBC, U&E, CRP, Ca, LFT, Mg, glucose).
  • Look for symptoms/signs of infection (skin, chest, urine, CNS) and perform appropriate cultures and imagine depending on clinical assessment.
  • ECG - because acute coronary syndrome can cause delirium.
24
Q

Describe the ‘M’ in the delirium time bundle.

A
  • Management plan
  • Initiate treatment of all underlying causes found above.
25
Q

Describe the ‘E’ in the delirium time bundle.

A
  • Engage and explore
  • Engage with patient / family / carers - explore if this is unusual behaviour.
  • Explain diagnosis of delirium to the patient, family and carers (use delirium leaflet).
  • Document diagnosis of delirium.
26
Q

In some cases, urgent neuro-imaging will be required. What are the circumstances?

A
  • If the patient is anti-coagulated.
  • History of fall with head injury.
  • New focal neurological signs.
27
Q

Describe the treatment of delirium.

A
  • Identify and treat the underlying cause.
  • Reduce or remove culprit medications.
  • Maintain hydration and nutrition.
  • Reorientation strategies.
  • Maintain mobility.
  • Normalise sleep wake cycle.
  • Pharmacological management.

Prevention is better than cure!

28
Q

Describe the non-pharmacological management options for deliruim.

A
  • Re-orientation strategies and distraction.
  • Involve families / familiar people.
  • Use glasses / hearning aids.
  • Keep mobile and avoid restraints.
  • Promote sleep with a quiet room at night, bright light during the day and dim at night, avoid day time napping.
29
Q

Describe the appropriate communication strategies for dealing with a delirium patient.

A
  • Introduce yourself and explain who you are, what you are doing and where you are - may need to repeat.
  • Useful to explain delirium.
  • Smile, make eye contact and be friendly.
  • Don’t argue about delusions, try to persuade but if not possible use distractions.
  • Get help from familiar faces (family, carers).
  • Remember the patient may be aggressive because they are scared.
30
Q

Describe the boundaries of pharmacological treatment of delirium.

A
  • No evidence for prevention of delirium with medications.
  • May need low dose sedation if very agitated / aggressive / hallucinating.
  • Start low and go slow.
  • Stop as soon as possible.
  • Alcohol withdrawl protocol.
31
Q

What are the medications which can be used in delirium?

A
  • Antipsychotics (e.g. haloperidol)
  • May reduce duration
  • Increased risk of stroke
  • Increased risk of falls
    • Not in parkinson’s or lewy body disease
  • NNH 21.9 at 1 year
  • Benzodiazepines (e.g. lorazepam)
  • May worsen / lengthen delirium
  • Increased falls risk
32
Q

Give exmaples of prevention strategies for delirium.

A
  • Vision (glasses)
  • Hearing (aids)
  • Avoid sleep deprivation
  • Promote mobility (try to avoid drips and catheters)
  • Hydration
  • Orientation and activity programme - volunteers / family
  • Environment - lighting, clock, calendar
  • Avoid frequent moves (and admission if possible)
33
Q

Describe the follow-up of a delirium patient.

A
  • Can take months to resolve so is often still present on discharge.
  • Explanation and information (If they do remember what happened during the delirium it can be terrifying so it is important to the give the patient all the information).
  • Repetitive cognitive testing.