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Flashcards in Delirium Deck (18)
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1
Q

What is delirium?

A

Also known as ‘acute confusional state’

Acute (hr-d onset), fluctuating syndrome of disturbed:

  • Consciousness
  • Attention
  • Cognition
  • Perception
2
Q

Outline the DSM-5 criteria for delirium

A

All of:

  • Disturbance in attention and awareness from baseline
  • Acute onset (typically hours-days); fluctuating severity
  • Additional cognitive disturbance
    • eg. memory deficit; disorientation; language; perception
  • Not better explained by another neurocognitive disorder
  • Evidence of precipitating event responsible for disturbance
3
Q

Describe the illness course of delirium

A
  • Sudden onset
  • Fluctuating course
  • Gradual resolution: up to 6-months
    • Following effective treatment of underlying cause
4
Q

List the three clinical presentations of delirium

A
  • Hyperactive delirium
  • Hypoactive delirium
  • Mixed delirium
5
Q

Describe hyperactive delirium

A
  • Psychomotor agitation
  • Increased arousal
  • Inappropriate behaviour
  • Hallucinations: commonly visual
  • Delusions: commonly persecutory
  • Restlessness and wandering are common
6
Q

Describe hypoactive delirium

A
  • Psychomotor retardation
    • Appear quiet or withdrawn
  • Lethargy
  • Reduced appetite
  • Excess somnolence (drowsiness)
7
Q

Describe mixed delirium

A

Combination of hyperactive and hypoactive delirium with varying presentation over time

8
Q

Name three predisposing factors for delirium

A
  • Elderly or very young
  • Pre-existing dementia
  • Sensory impairment: eg. visual or hearing
  • Post-op (especially cardiac)
  • Alcohol abuse; benzodiazepine-dependent; poor nutrition
  • Serious and/or multiple illnesses; polypharmacy
  • Lack of stimulation
9
Q

Provide five precipitating factors for delirium

A

Delrium is usually multifactorial

  • UTI; chest infections; infected pressure sore; sepsis
  • Hyperglycaemia; hypoglycaemia; electrolyte abnormalities
  • MI; heart failure; stroke; intracranial bleed
  • Thyroid dysfunction; PE; COPD exacervation
  • Urinary retention; constipation; malnutrition
  • Severe uncontrolled pain; major surgery
  • Medication changes; alcohol intoxication or withdrawal
    • eg. opiods; benzodiazepines; steroids
  • Hospital admission; emotional stress; sleep deprivation
10
Q

Name five complications of delirium

A
  • High mortality (20% during admission, up to 50% at 1yr)
  • Increased duration of stay
  • Nosocomial infections
  • Institutionalisation and/or re-admission
  • Increased risk of:
    • Dementia
    • Falls
    • Pressure sores
    • Continence problems
    • Functional impairment; distress for self/carers
11
Q

What is the association between delirium and dementia?

A

Delirium causes neuronal death ➔ Independent cause (3x more likely) for dementia development and progression

Pre-existing dementia is a predisposing factor for delirium

12
Q

Request three investigations for suspected delirium

A
  • Cognitive testing: 4AT; MoCA; Addenbrooke’s
  • Urinalysis
  • Sputum culture; CXR
  • FBC; CRP
  • U+Es; calcium
  • HbA1c
  • TFTs
  • Haematinics: eg. B12; folate
  • EEG
13
Q

What are the management principles for delirium

A
  • Identify and treat underlying causes
  • Environmental and supportive measures
  • Avoid sedation unless severely agitated or a risk
  • Regular clinical review and follow-up
14
Q

Name four environmental and supportive measures in the management of delirium

A
  • Maintain hydration and nutrition
  • Physical environment
    • eg. Safe environment; good lighting; noise reduction; clocks and calendars; hearing and visual aids
  • Human environment
    • eg. Same staff; firm clear communication; routine; prevent transfer
  • Control of distressing physical symptoms
  • Avoid unnecessary procedures
  • Promote healthy sleep patterns
15
Q

Name three physical environmental factors for optimal management of delirium

A
  • Safe environment
  • Adequate lighting
  • Noise reduction
  • Clocks and calendars
  • If appropriate, hearing and visual aids
16
Q

Name two human environmental factors for optimal management of delirium

A
  • Same group of staff
  • Firm clear communication
  • Routine
  • Prevent transfer
  • Education for those interacting with patient
17
Q

Outline the managment of a person with delirium who is distressed or considered a risk to themselves or others?

A
  • Verbal and non-verbal de-escalation
  • Short-term haloperidol
    • Lowest clinically appropriate dose; titrate to symptoms
    • Use with caution or none if Parkinson’s or Lewy body
18
Q

Differentiate dementia from delirium

A

Delirium has altered consciousness and attention

Dementia:

  • Gradual onset (months to years); progressive deterioration
  • Normal consciousness; perceptional disturbances occur later
  • Normal sleep-wake cycle

Delirium:

  • Acute onset (hours to weeks); fluctuating course
  • Impaired consciousness; perceptional disturbances common
  • Disrupted sleep-wake cycle.