Week 2 - Delerium Flashcards
What are the two assessment tools used to assess/diagnose delirium ?
- 4AT
- CAM (confusion assessment method)
What are some medication side effects that can contribute to delirium ?
- poly pharmacy
- hyponatraemia
- constipation
- drowsiness
- hypotension
- dehydration
- high anticholinergic burden inhibiting the parasympathetic NS
Which patient demographic is not advised to be prescribed anticholinergic medications ?
the elderly (65+)
What is ‘anticholinergic burden’ ?
the cumulative effect of all drugs a patient is on which possess anticholinergic effects
What scoring system is used to calculate a persons anticholinergic burden risk ?
ACB score
What does a high anticholinergic burden (ACB score) but elderly patients at higher risk of ?
- falls
- delirium/confusion
- death
What meds can be used in the case of delirium ?
- meds to treat underlying cause
- wouldn’t use meds to treat the symptoms of delirium unless Pt becomes harm to self or others = sedatives
What is a mneumonic used to list all the risk factors for delirium ?
PINCH ME + cognitive decline and previous delirium
Pain
Infection
Nutrition (malnurishment?)
Constipation/urinary retention
Hydration
Meds (psychotropics, analgesics, opioids, anticholinergics…)
Environment (new environment, necessary aids available e.g glasses or hearing aids)
What are some non-pharmacological methods to decrease delirium ?
- orient patient to time and place
- encourage mobility
- surround Pt with familiar items
- promote normal sleep cycle
- encourage intake of food and fluids
- provide necessary aids (glasses, frame, hearing aids etc)
- friends/family visits
- review med list
What is included in the 4AT assessment ?
- alertness
- oriented to age, DOB, place, current year
- attention (list months backwards)
- acute or fluctuating course (significant change to alertness, cognition or other mental fluctuation over past 2 weeks that is still evident in last 24hrs)
What does each of the 4AT scores suggest ?
0 = unlikely to be delirium or sever cognitive impairment
1-3 = possible cognitive impairment
4+ = possible delirium and/or cognitive impairment
highest 4AT score is 12
What are the criteria for a diagnosis of delirium according to the CAM assessment for delirium ?
- presence of acute confusion with fluctuation
AND
- inattention (difficult concentrating)
AND EITHER…
- disorganised thinking
OR - altered level of consciousness (heightened/agitated or drowsy)
Alcohol withdrawal can cause delirium, what should be used to treat alcohol withdrawal ?
oral benzodiazepines
e.g chlordiazepoxide
What legal document needs to be completed in a case where a delirious patient requires pharmacological sedation ?
DoLS
(Deprivation of Liberty Safeguards)
Name 3 drugs that can be used to sedate delirious patients (only when absolutely necessary)…
- haloperidol
- risperidone
- lorazepam
What is the criteria for an assessment of mental capacity ?
- is there impairment/disturbance of mind or brain ?
- Pt lacks capacity if answer to Q1 was yes and they’re unable to do 1+ of the following:
- understand relevant info
- retain that info
- weigh up pros and cons
- communicate decision
What causes delirium ?
the interaction between a vulnerable patient (elderly, frail, dementia, sensory impairment) and inflammatory stimulus (infection, surgery, drugs, dehydration)
Which wards do you see the most incidence of delirium on ?
- geriatric
- orthopaedic (post surgery)
- ITU
What % of surgical patients are affected by delirium ?
50%
What are some adverse outcomes associated with delirium ?
- increased length of hospital stay
- increased risk of falls
- increased risk of functional decline
- increased incidence of dementia
- increased risk of institutionalisation
- increased mortality
What are the three subtypes of delirium ?
- hyperactive delirium (aggressive, restless, insomnia, heightened state of arousal)
- hypoactive delirium (drowsy, withdrawn, somnolence)
- mixed delirium (fluctuates between the two types above)
which type of delirium is least recognised and carries the highest risk of subsequent death ?
hypoactive
what is the path o physiology of delirium ?
unclear - potentially inflammatory changes in brain causes by stressors
Why are urine dipsticks not recommended to diagnose UTIs in elderly people?
because roughly 50% of older people have harmless bacteria in their urine, and the dipstick cannot differentiate between this bacteria and harmful bacteria
What will a urine dipstick be positive for when there are any type of batteria in the urine ?
nitrites
leukocyte esterase (WBCs)
What are common findings on a urine dip in an elderly patient ?
- protein
- glucose
- nitrites
- WBCs
Why is it best not to urine dip an elderly person ?
it’s hard to ignore a positive urine dip, but that may not be indicative of infection in the elderly
- don’t want to put elderly on unnecessary antibiotics as can lead to resistance and C.diff
Instead of using a urine dip to diagnose UTI in elderly, what signs and symptoms should you look for ?
- dysuria
- frequency or urgency
- new incontinence
- delirium
- suprapubic pain
- haematuria
- check catheter is draining
What are the different types of laxative ?
- bulk forming (retains water in stool to increase faecal mass and start peristalsis)
- osmotic (draws water into bowels)
- stimulant (stimulates peristalsis)
- faecal softeners (increases fractal fluid to pass easier)
which medication is given to patients experiencing agitational delirium, after treating the underlying cause and making evnvuronmental changes has failed ?
oral haloperidol
(an anyipsychotic)
Which conditions/diseases are contraindicated in use of antipsychotics (e.g haloperidol) in elderly patients with hyperactive delirium ?
parkinson’s
leah body dementia
What is an alternative sedative for patients with hyperactive delirium that also have parkinson’s disease ?
oral lorazepam
(instead of haloperidol, because that cna worsen symptoms of parkinson’s)
What is one side effect caused by lorazepam in the elderly ?
increased risk of falls
what is a contraindication of lorazepam ?
sleep apnoea
