w6: Delirium, Caregivers Flashcards
Delirium Definiton
-acute, often reversible -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.
neuropsychiatric examination delirium
Neglect of Illness
Anosognosia:
- ppl w delirium unconcerned/ deny being ill
- lack of insight and impaired judgement
- ie. to give or withold informed conset for medical investigation –> tricky due to fluctuating mental states
neuropsychiatric exam delirium
misperceptions, halluciantions, delusions
- experience distortions of shape or size
- visual hallucinations more common than auditory
- delusions present but fragmented, less organised, more transient than someone w psychosis
- visuoconstructive tasks - clock drawring- can be very impaired
Caregivers
who? nurses, Dr, family members
DEMENTIA - sympt + psych/ beha problm
Cognitive symptoms
Memory loss
Executive dysfunctions
Agnosia
Etc.
Psychiatric and behavioral problems
Apathy
Hallucinations
Depression
Aggression
Restlessness
Etc.
duration = few years/ decades
CAREGIVERS - HYPOTHESES
Wear-and-tear hypothesis
Over time caregivers’ functioning steadily declines as a result of prolonged stress
Adaptation hypothesis
Caregivers adapt to the demands of caregiving over time and their physical and
mental health stabilizes or improves
Trait hypothesis
In spite of dementia progressing, caregivers function well because of individual
characteristics (e.g. personal resources, social support, coping skills)
Caregiver Dynamics
Caregiver Predictors: Factors such as personality and caregiving strategies impact the caregiver’s ability to handle challenges effectively.
Behaviour of the Person with Dementia: Symptoms like memory loss and aggression create stress and require constant adaptation by the caregiver.
Caregiver Consequences: The stress associated with these challenges impacts the caregiver’s mental health, quality of relationships, and overall well-being.
severity of dementia and prognosis can differ b/w ppl –> caregiver must continuosly adapt
Caregiver Burden
a multidimensional response to physical,
psychological, emotional, social and financial stressors associated with
the caregiving experience
Caregiver’s burden can not be strictly tied to the severity of dementia
or length of time someone has provided care
caregiver burden
early stages of dementia
Often characterized by:
Memory disturbances
Personality changes
Diagnosis: e.g. Alzheimer’s disease
Relief
But also many questions and concerns
caregiver burden
middle stages of dementia
Often characterized by
Severer memory disturbances
Greater personality changes
Impairments in abstract thinking and judgment
Result: person with dementia is confused and asks questions repetitively
Anger and agitation
Depression
In both caregivers and people with dementia
caregiver burden
late stages of dementia
Often: nursing home placement
Decrease of caregiver burden?
Not necessarily
Improvement: no longer dealing with unpredictable behavior and poor
health status on a daily basis
Burden: increase of financial strains, loss of companionship, concerns
about quality of nursing home care
caregiver predictors
Gender Differences
- female tend to feel more intensely than male caregivers
- females spen more time on tasks
- females percieve greater strain and burden related to caregiving
3 things to keep in mind:
1. great variation among individuals in nature and impact of caregiving
2. gender differences more pronounced in adults
3. men are not immune to effects of caregiving
caregiver prediction
relation to person w dementia.
- spuse caregivers exhibit higher levels of depression and stress (maintain role for longer, greater likelihood to also develop health problems)
- adult child-caregivers are often juggling multiple roles
- adult child-caregivers frequently experience confluct w their siblings over caregiving issues
caregiving predictors
coping
coping: cognitive and behavioural attempts to manage specific demands that are appraised as stressful
problem focused coping: internal strategies that are used to manage one’s emotions
emotion focused coping: associated with higher levels of distress
active problem-focused coping associated with a greater caregiver well-being.
caregiving predictors
personality
some may be more likely to apprasie caregiving as stressful.
certain personality characteristics may be less effective in arranging social support.
Optimism and mastery ++
Neuroticism –
High levels of anger –
caregiver predictors
other factors
social support
health behaviour- physical activity, not smoking, limited alcohol consumption
caregiver consequence
caregivers with a high burden show:
- increased activity of HPA axis
- poor Ab response to influenza vacc.
- high level of caregiver burden increase coronary heart disease risk
increased risk of:
- visiting physician
- medication use
- n of physical symptoms
- hospitalisations
- days of illness
- chronic illness
is an independent risk factor for mortality among spousal caregivers
caregiver burden
COMPARING DEMENTIA TO CANCER AND
DIABETES - CONCLUSION
Most caregivers take care of their parents
ØIrrespective of type of disease
ØPeople with dementia and cancer need more help with activities of
daily living than people with diabetes
ØPeople with dementia, cancer and diabetes all need support with
instrumental activities of daily living
+ve aspects of caregiving
caregivers:
- feel good ab work
- enhanced spirituality, self-efficacy, personal growth
- strenghten relationship
- improved attitude towards life
caregivers who find the +ve:
- less depressed
- focus on gains not losses
- rate quality of life higher
