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29 Cards in this Set

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What is the definition of delirium?

A state of mental confusion that develops quickly and usually fluctuates in intensity

What are the diagnostic criteria for delirium? (4)

-Disturbance in attention or arousal




-Change in cognition that develops over short period of time




-Tendency to fluctuate during the course of the day with disturbance of the sleep-wake cycle




-Evidence from the history, examination or investigations that delirium is a direct consequence of a general medical problem, drug withdrawal or intoxication

As well as the core diagnostic criteria for delirium, what other features are associated with it?

-Paranoid delusions


-Emotional changes


-Motor changes (slow/restless/agitated)


-Hallucinations

What is the less formal name sometimes given for delirium?

Acute confusional state

What is the prevalence of delirium in general hospital?

20%

How much more likely are patients with dementia likely to experience delirium?

5-10 times more likely

What are the major risks that delirium poses?

-Increased risk of mortality (40% 1 year mortality)


-Prolonged hospital admission


-Higher complication rates


-Institutionalisation


-3x increased risk of developing dementia

What are 5 predisposing RFs for delirium?

-Dementia


-Sensory impairment (e.g. vision)


-Old age (>65 years)


-Physical fragility


-Multiple co-morbidities

After acute delirium has been treated, what are some of the strategies in the long term management plan?

-Keep orientated and promote the familiar


-Facilitate hearing and vision (glasses, hearing aid etc)


-Keep hydrated and well fed


-Reduce medication


-Keep mobile and active


-Promote night time sleep


-Minimise provocation eg. noises, tubes, restraints

What drugs should be avoided in patients who have experience delirium?

-Anticholinergics


-Opiates

What are the 3 types of delirium and which is most common?

-Hyperactive


-Hypoactive (most common)


-Mixed

Which type of delirium is most commonly missed and why?

Hypoactive delirium because it may be mistaken for depression

What is hypoactive delirium characterised by? (4)

-Apathy


-Withdrawal


-Lethary


-Lack of motor activity

For hypoactive delirium, what types of complication is most likely?

Complications associated with low mobility and increased hospital stay ie. pressure ulcers

What are the main features of hyperactive delirium?


In terms of issues surrounding diagnosis and treatment, how does this differ from hypoactive?

-Increased motor activity


-Agitation


-Hallucinations


-Challenging behaviour




Issue is that though these patients are more likely to be diagnosed correctly, they are also more likely to be treated inappropriately with sedatives

What are common causes of delirium? (9)

-Any acute infection esp, UTI, pneumonia, sepsis


-Drugs or withdrawal


-Hypoxia


-Electrolyte imbalance


-Endocrine imbalance


-Head injury


-Faecal impaction


-Urinary retention


-Dehydration

What are the components of an examination of a patient to elicit cause of delirium? (6)

-Level of consciousness (AVPU or GCS)


-Cognitive function (AMT or MMSE)


-Infection screen


-Hydration and nutrition status


-Assess for urinary retention or faecal impaction


-Neuro examination plus speech

What are the steps of the AMT? (10)

Age


Time


Give address for recall


Year


Name of hospital


Recognition of 2 people


DOB


Year of WW1


Name of current monarch


Count backwards from 20




Don't forget to ask whats the earlier address?

Below what score is AMT classed as abnormal?

<8

What is the test specific to delirium?

CAM to be performed after failed AMT

What are the sections and criteria of CAM?

Delirium required present of 1 and 2 and either 3 or 4




1) Acute onset and fluctuating course


2) Inattention




3) Disorganised thinking




4) Altered level of consciousness (hyper or hypo)

What are the medical terms for the following to do with altered level of consciousness?




1) Normal


2) Hyperalert


3) Drowsy but easy to arouse


4) Difficult to arouse


5) Unarousable

1) Alert


2) Vigilant


3) Lethargic


4) Stupor


5) Coma

What are the 1st line investigations for delirium? (9)

Urinalysis


CXR


LFTs


ECG


CRP


Renal function and electrolytes


BM


TFT


FBC

What is the treatment of delirium?

-Identify and treat underlying cause


-Manage symptoms of delirium


-Prevent complications


-Explain to patient and relatives

What are some ways to manage the symptoms of acute delirium? (8)

-Nurse in optimal environment


-Promote orientation


-Analgesia (not opiates)


-Maintain hydration and nutrition


-Good sleep hygiene


-Consider 1 to 1 care


-Use least restrictive option with wandering patients


-Keep use of sedatives to a minimum

What are some of the complications associated with delirium?

-Pressure ulcers


-Falls


-Infections


-Malnutrition


-Functional decline


-Incontinence

Which is the more detailed test, AMT or MMSE?

MMSE is more detailed




AMT is a screening test and a failed result should be followed by a MMSE

Though you should not sedate a patient who is delirious under normal circumstances, if they are not responding to behavioural measures and are being threatening to other patients on the ward, which sedative would be given and by what route?

Lorazepam IM

What common drugs can induce delirium (9)

-Beta blockers


-Lithium


-Benzodiazepines


-Warfarin


-Furosemide


-TCAs


-Digoxin


-Steroids


-Anti-histamines


-Statins