Definition- Disturbed consciousness
- Change in cognition
- Acute onset and fluctuating course
- Cause by a medical condition or treatment
Urgency
- Many LIFE-THREATENING conditions can cause delirium
- => Assess as a priority
- Especially if young, healthy
- May need to aggressively treat the underlying cause
Pathogenesis
- 1. Medications
- Sedatives
- Steroids
- Steroid psychosis : If high dose for a long time
- Opioids
- Antihistamines
- Digoxin
- Lithium
- 2. Infection
- 3. Metabolic
- Electrolytes
- Hypercalcaemia
- Cancer
- Unlikely to be from hyperparathyroidism (slower rise => adaptation)
- Hyponatraemia
- Hypernatraemia
- Hypophosphataemia
- Refeeding syndrome
- Brain can't make enough ATP
- Hypomagnesiumaemia
- cf Use is fitting (opposite effect)
- Endocrine
- Diabetes
- Thyroid storm
- Hypothyroidism
- Cushing's
- Addison's
- 4. Failure
- Heart, resp, renal, liver
- 5. CNS
- Meningitis
- Beware atypical presentations in the elderly
- e.g. Temp. may be low as well as high
- Listeria is common is elderly (as well as infants)
- From out of date dairy products (can't read the label)
- SDH, psychiatric condition, transient global amnesia (TGA), epilepsy, hypertensive encephalopathy
- 6. Physical
- Dehydration
- Pain
- Don't forget to give decent pain relief for hip fractures!
- Catheters
- Use condom catheter or pads
- Lines
- Hypo/hyperthermia
Differentials
- Dementia
- Stroke
- Frontal lobe
- Wernicke's
- Occipital
- Cortical blindness => Seeing snakes
- Non-convulsive status epilepticus
- Primary psychiatric illness
- Psychosis
- Depression
- Bipolar
- Schizophrenia
Confusion Assessment Method (CAM)
- Feature 1: Acute Onset and Fluctuating Course
- Is there evidence of an acute change in mental status from the patient’s baseline?
- Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
- Feature 2: Inattention
- Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
- Feature 3: Disorganized thinking
- Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
- Feature 4: Altered Level of consciousness
- This feature is shown by any answer other than “alert” to the following question:
- Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])
- The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4
IQ code - For collateral history
- Compare with the patient 10 years ago
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1
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2
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3
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4
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5
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1
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Remembering things about
family and friends, eg occupations, birthdays, addresses
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Much improved
|
A bit improved
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Not much change
|
A bit worse
|
Much worse
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2
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Remembering things that have
happened recently
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Much improved
|
A bit improved
|
Not much change
|
A bit worse
|
Much worse
|
3
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Recalling conversations a few
days later
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Much improved
|
A bit improved
|
Not much change
|
A bit worse
|
Much
worse
|
4
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Remembering her/his address
and telephone number
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Much improved
|
A bit improved
|
Not much change
|
A bit worse
|
Much worse
|
5
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Remembering what day and
month it is
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Much improved
|
A bit improved
|
Not much change
|
A bit worse
|
Much worse
|
6
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Remembering where things are
usually kept
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Much improved
|
A bit improved
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Not much change
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A bit worse
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Much worse
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7
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Remembering where to find
things which have been put in a different place from usual
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Much improved
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A bit improved
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Not much change
|
A bit worse
|
Much worse
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8
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Knowing how to work familiar
machines around the house
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Much improved
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A bit improved
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Not much change
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A bit worse
|
Much worse
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9
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Learning to use a new gadget
or machine around the house
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Much improved
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A bit improved
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Not much change
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A bit worse
|
Much worse
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10
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Learning new things in
general
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Much improved
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A bit improved
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Not much change
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A bit worse
|
Much worse
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11
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Following a story in a book
or on TV
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Much improved
|
A bit improved
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Not much change
|
A bit worse
|
Much worse
|
12
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Making decisions on everyday
matters
|
Much improved
|
A bit improved
|
Not much change
|
A bit worse
|
Much worse
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13
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Handling money for shopping
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Much improved
|
A bit improved
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Not much change
|
A bit worse
|
Much worse
|
14
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Handling financial matters,
eg the pension, dealing with the bank
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Much improved
|
A bit improved
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Not much change
|
A bit worse
|
Much worse
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15
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Handling other everyday
arithmetic problems, eg knowing how much food to buy, knowing how long
between visits from family or friends
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Much improved
|
A bit improved
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Not much change
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A bit worse
|
Much worse
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16
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Using his/her intelligence to
understand what’s going on and to reason things through
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Much improved
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A bit improved
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Not much change
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A bit worse
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Much worse
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Management
- INVOLVE PHYSIOS EARLY
- Avoid
- Treat
- Support
- Aspiration, hydration, nutrition, mobility, skin + pressure care, incontinance
- Control
Medication
- Haloperidol
- Lorazepam
- Quetiapine
- NOT risperidone/olanzapine
Prevention- Orientation protocols
- Cognitive stimulation
- Keep on general ward
- Beware of over- and under- stimulation
- Don't move at night
- Early mobilisation
- Minimise restraint
- Adequate hydration
Notes- ACS vs Delirium
- ACS is hypoactive
- Delirium is hyperactive
- Aim for <6 drugs in elderly care
- Differentials co-exist in 50% of cases
- Focal neurology or trauma => Immediate CT head
- Delirium => 2x mortality
- The key intervention is PHYSIOTHERAPY
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