w6: Delirium, Caregivers Flashcards
Delirium Definiton
Delirium is an acute, often reversible condition characterised by a sudden onset of confusion, altered levels of consciousness, and disruptions in attention, cognition, and perception. It is commonly associated with an underlying medical or neurological condition
synomyms delirium
inattention
altereld sleep-wale cycle
psychomotor agitation or reardation
perceptual disturbance
acute onset
altered level of conciousness
disorientation
memory impairment
disorganised thinking
inattention
Delirium DSM-5
A. attention disturbance and awareness
B. disturbance develops over short period of time (hours/days), change from baseline attention and awareness, fluctuates in severity during course of day.
C. additional disturbance in cognition (memory, disorientation, language, visuospatial)
D. disturbances in criteria A adn C are not better explained by other disorder
E. evidence from history, or physical examination that disturbance is direct physiological consequence of another medical condition
why important to identify delirium?
general hospital incidence in older ppl 6-56% w delirium.
may often be misattributed as dementia
can interfere with assessment of other clinical probelms
can be thought of as ‘acute brain failure’
can be a marker for a vulnerable brain with reduced reserve capacities
might lead to permanent cognitive decline and dementia in some people
Causes Delirium
the etiology of delirium is often multifactorial (w many ppl having multiple causes simulatniously)
Energy deprivation: hypocalcemis, hypoxemia, impaired perfusion
Metabolic Derangements: hypoatremia, hypernatremia, hypercalcemia, hyperglycemia
CNS injury: stroke, intracranial bleed, demyelinating disease
Neoplasm: malignant gliomas, metastatic tumors, lymphome
Drug Toxicity: anticholinergics, dopaminergic agonist, seretonin syndrome, lithium toxicity.
CNS infection: encephalitis, meningitis, HIV, syphilis
Predisposing (non-modifiable)/ precipitating (modifiable) factors
modifiable: pain, emotional distress, restrains, medications, polypharmacology, infections
potnetialy modifiable: sensory impairment, immobilization, substance abuse, acute severe illness
non-modifiale: age >65 ys
- male sex, cogntive impairments, history of delirium, burden of comorbidities, surgery, terminal illness
dementia is one of the most prominent risk factors for delirium.
the more predisposing factors, the fewer precipitating factors needed to tip the sensiive balance - leading to delirium
protective factrs: timely recognition of ppl at risk, targetted multicomponent interventions
Multifactorial Model of Delirium in older ppl
onset of delirium is dependent on a complex interaction b/w patient’s baseline vulnerabilty (predisposing factors) at admission, and precipitating factors or nocious insults occuring duirng hospital admission.
Subtypes of Delirium
hyperactive, hypoactive, mixed activity
Hyperactive- Hyperapery
- person is confused, restless, agitated. psychomotor hyperactivity, abnormal allertness and arousal. - inapropriate startle response
hypoactive- hypoalert
- person is confused, lethargic, appears depressed. psychomotor hypoactivity and drowsiness. may sleep excessively, halluciantions
mixed level- person has alternating periods of both hyperactivity and hypoactivity
fluctuations b/w the types occur, none are stable over time
may be mistaken for psychiatric disorder (ie. psychosis, depression)
may be mistaken for cognitive disorder (dementia)
Neuropsych/ Cognitive Sympt Delirium
Neuropsych:
- most frequent: sleep-wake cycle disturbance - 73%
- least frequent- delusions - 9%
cognitive:
- inattention -most freq 73%
- disorientation 42%
- visuospatial deficits 64%
- LTM deficients
- STM deficients
- psychomotor retardation
- language disturbance
Recognition of Delirium
gold standard: psychiatric evaluation
diagnosis made on clinical grounds
delirium affects cortex diffusely
delirium can have widely variable symptoms (cogntition, mood, anxiety, psychotic)
can result in any neuropsychiatric symptoms
Job of clinician: differentiating delirium from other conditions with similar/ overlapping symptoms
CONSEQUENCE: diagnosing of delirium is difficult adn delirium is often missed, misattributed, and underdiagnosed.
recognising delirium .2
delirium characterised by acute (hours to days) change in baseline cognition, behaviour and function in mental status.
collateral info from family and caregivers over previous 24-48 hrs needed.
ppl w delirium deostrate fluctuating attention, awareness, concisousness
conflicting reports about patients mental status at different times from different caregivers
Assessment Delirium:
Confusion Assessment Methd
CAM
structured tool for diagnosing delirium in clinical settings
key features:
1.acute onsrt & fluctuating course
2.inattention
3. disorganised thinking
4.altered levels of conciousness
diagnostic criteria:
- must have 1 and 2
- plus, either 3 or 4
steps to administer:
1. observe for changes in mental status and fluctuations
2. assess attention w focused tasks (ie. counting backwards)
3. evaluate thinking for coherence and logical response
4. rate symptoms- determine presence of 4 features
Neuropsychiatric Examination ppl Delirium
Behaviour
Agitation
- maybe due to disorientation
- ie. might think they’re at home not hospital.
- consequences: ppl tend not to comply w bed restrictions, or intravenous or oxygen tubing
Apathy or Withdrawl:
- may appear depressed fur to blunted affect, decreased motivation or sleep disruption
- ie. person may fall asleep during interview
Affect
emotional lability
- ppl w delirium may show a wide range of emotions: tearfulness, sadness, anxiety, euphoria
- can have more than oen of thse emotions
Neuropsychiatric Examination ppl Delirium
Cognition
Attention:
- may not remember instructions
- cannot do calculations that involve concentration (ie. asking someone to spell something backwards)
Disorientaiton:
- ppl with delirium may show disorientation to date, place and circumstace.
Memory:
may not remember recent events
Language:
anomic aphasia
paraphasia
impaired comprehension
agraphia
word-finding difficulties
Abstract reasoning:
- thought processes requiring sustained concentration, problem solving, abstract reasoning
probelm solving/ executive functions
- impaired judgement regarding own situation
Delirium + Mini Mental State Exam
delirium disrupts cognitive function in surgical patients, with longer episodes leading to greater and more prolonged impairments.
While some recovery occurs over time, patients with delirium, particularly those experiencing it for ≥3 days, may not fully regain their pre-surgery cognitive levels, highlighting potential long-term effects.
