Week 2 - Delirium Flashcards
What is delirium?
- AKA “acute confusional state”
- an acute (hours – days), fluctuating syndrome of disturbed consciousness, attention, cognition, and perception.
- Personality changes and psychotic features may occur (visual hallucinations > audilbe)
What are the 3 types of delirium?
Describe the 2 main ones
Hyperactive – agitated and wandering
- Agitation, restlessness
- Wandering
- Loss of inhibition, innapropriate behaviour
- Hallucinations
Hypoactive – quiet and withdrawn
- Lethargy
- ↓ concentration
- ↓ appetite
- Appears quiet or withdrawn
- May have carphologia (or carphology) - a lint-picking behavior that is often a symptom of a delirious state.
- picking or grasping at imaginary objects, as well as the patient’s own clothes or bed linens. This can be a grave symptom in cases of extreme exhaustion or approaching death.
- Aka floccillation
- Worse prognosis
Mixed
What is a predisposing factor?
a factor that increases the risk of developing the disease
In people with predisposing factors for delirium, a relatively benign additional factor, e.g. single dose of hypnotic medication, may precipitate dilerium
Name some predisposing factors for delirium
- Older age (over 65 years).
- Cognitive impairment (such as dementia).
- Frailty/multiple comorbidities (such as stroke or heart failure).
- Significant injuries such as hip fracture.
- Functional impairment (for example immobility or the use of physical restraints such as cot sides).
- Iatrogenic events (such as bladder catheterization, polypharmacy, or surgery).
- History of, or current, alcohol excess.
- Sensory impairment (such as visual impairment or hearing loss).
- Poor nutrition.
- Lack of stimulation.
- Terminal phase of illness.
What both increases the risk of future episodes of delirium and must also be counselled on after an episode of delirium?
Previous delirium increases the risk of future delirium! Counsel families / carers to watch out for signs. Still likely to need to come to secondary care
What is a precipitating factor?
Name some for delirium
A trigger that speeds the onset of a disease
For delirium:
- Immobility
- Use of physical restraint
- Urinary catheter
- Iatrogenic events
- general anaesthesia
- Malnutrition
- Dehydration
- Psychoactive medications
- Intercurrent illness
- Withdrawal from benzos or alcohol
What is a mnemonic to remember causes of delirium?
PINCH ME (W)
What does PINCH ME(W) stand for?
= underlying causes of delirium
- P – Pain, post-operative cognitive dysfunction
- I – Infection; UTI, pylonephritis, chest infection, GI, skin / soft tissue. Remember Sepsis
- N – Nutrition is poor, Neurological (stroke, seizure)
- C – Constipation / faecal impaction or Can’t pee - Urinary retention
- H – deHydration (meant to drink 1.5-2L / day), Hypoxaemia
- M – Medication, MI (may be painless /silent)
- E – Environment change, Electrolyte Imbalance e.g. hypercalcaemia, hypoglycaemia
- W – Withdrawal – alcohol or benzodiazepines (or steroids?)
What are the complications of delirium? 11
- Increased mortality.
- Mortality rates in those diagnosed with delirium in hospital are twice those of people with similar medical conditions who do not develop delirium
- After hospital discharge, the risk of dying for a person with delirium is doubled for about 12 months
- Increased length of stay in hospital.
- Nosocomial infections aka hospital acquired infections
- Increased risk of admission to long-term care or re-admission to hospital.
- Increased incidence of dementia.
- People with delirium are three times more likely to develop dementia. One prospective cohort study (n = 203) found that the relative risk of developing dementia in the 3 years following delirium trebled [Rockwood, 1999].
- Falls.
- Pressure sores.
- Continence problems.
- Malnutrition.
- Functional impairment.
- Distress for the person, their family, and/or carers.
What is essential in order to decide if a patient’s behaviour is altered?
A collateral history from someone who knows the patient’s normal baseline is essential
How do symptoms of delirium appear?
Acutely (within hours to days)
Typically fluctuating throughout the day, worse at night
Name some symptomatic features of delirium in general (obvs will differ with type) - 10 listed
- memory disturbances (loss of short term > long term)
- may be very agitated or withdrawn
- disorientation
- mood change
- visual hallucinations
- disturbed sleep cycle
- poor attention
- paranoid
- picking at things, tearing things up
- hard to examine or take hx (even patients with dementia can normally copy)
What tools are available for assessing cognition in a delirious patient?
- CAM - The Confusion Assessment Method based on ICD 10 criteria for delirium.
- AMT4: (short version of AMT 10!) Ask the patient the following – their age, their date of birth, the current year and the current location/place
What diagnostic tool is used for delirium?
4AT - rapid assessment test (incorporates short version of AMTS 10 + 3 other criteria)
What does the 4AT involve?
4AT (incorporates short version of AMTS 10 + 3 other criteria)
- Alertness
- Normal/Fully alert/Mild sleepiness on waking = 0
- Clearly abnormal (drowsy/hypoactive or agitated/hyperalert) = 4
- AMT4: Ask the patient the following – their age, their date of birth, the current year and the current location/place
- No mistakes = 0
- 1 mistake = 1
- 2 or more mistakes/untestable = 2
- Attention: Ask the patient to name the months backwards starting at December
- 7 or more correctly = 0
- Less than 7 or does not attempt = 1
- Untestable (drowsy/inattentive) = 2
- Acute and Fluctuating course
- No = 0
- Yes = 4
What 4 features are part of the CAM assessment method for delirium?
Delirium = features 1 + 2 + either 3 or 4
-
Acute onset and fluctuating course
- PLUS
-
Inattention (counting backwards or reduced attention during review)
- PLUS
-
Disorganised thinking (incoherent disorganised speech)
- OR
- Altered level of conciousness (hyperalert, hypoalert, or both)
