-
Delirium
Definition
- Syndrome composed of disturbances of consciousness, attention (arousal), and cognition, with abrupt onset and fluctuating course
- Etiology: related to medical causes
- -Increased in elderly population
-
Altered mental status
Ddx
"MOVE STUPID"
- -Metabolic → thiamin B12
- -Oxygen (lack of)
- -Vascular (hypertensive emergency)
- -Endocrine/Electrolytes - diabetes, hyper-/hypo-Na, Ca
- -Seizures/Structural - hydrocephalus, post ictal
- -Trauma/Tumor
- -Uremia
- -Psychiatric
- -Infection
- -Drugs
-
Approach to altered mental status
- Easily treatable/reversible altered mental status:
- -Thiamin deficiency → thiamin
- -Hypoglycemia → D50
- -Opiate overdose → Naloxone
- Rule out life threatening conditions:
- -Abnormal neurologic exam: mass effect, tumor
- -Fever, HA, nuchal rigidity, AMS: r/o meningitis
- -Status epilepticus: benzodiazepines
- -Hypertensive emergency: anti-hypertensives
- -Hyperthermia: cooling measures
-
Delirium
impact
- Affects 15-50% of hospitalized patients
- 37% of postoperative patients
- Unrecognized in 70% of patients
- Increased length-of-stay (5-8 extra days/pt)
- loss of independence
-
Delirium
clinical features
- Disturbances of consciousness, arousal, awareness
- Attention disturbances
- Disorientation
- Cognitive disturbances
- Perceptual disturbances
- Disorganized thinking
- Delusions
- Psychomotor disturbances
- Sleep-wake cycle disturbances
- Acute onset, fluctuating course
-
Risk factors for delirium
- Patient:
- -Age > 65
- -Dementia
- -Functional dependence or immobility
- -Multiple comorbidities
- -Multiple medications
- -Chronic renal disease
- -Visual or hearing impairment
- Situation:
- -infection at hospital admission
- -Electrolyte abnormalities
- -Hypoxia, hypoglycemia
- -Medications
- -Neurologic disorder
- -Untreated pain
- -Dehydration
- Environment:
- -Excessive noise
- -Interrupted sleep
- -Unnecessary stimuli
- -Urinary catheter
- -Physical restraints
-
Assessing risk
- Risks:
- -Cognitive impairment
- -Severe illness
- -High BUN/creatinine
- -Visual impairment
- Probable outcomes:
- -0 points: low risk 10%
- -1-2 points: moderate risk 25%
- -3-4 points: high risk 80%
-
Delirium vs depression
- Hypoactive delirium:
- -Hypoaroused, drowsy
- -Abrupt onset
- Depression:
- -Normal level of arousal
- -Gradual onset
-
Confusion assessment method (CAM)
- I. Acute change and fluctuation in mental status from patient's baseline
- II. Inattention: dificulty focusing attention
- III. Disorganized thinking
- IV. Altered level of consciousness (hyperalert, lethargic, stupor, etc.)
- (+) CAM - presence of delirium;
- I, II, AND either III or IV
-
HELP intervention
- Delirium can be prevented (...)
- 10% incidence in intervention group
- 15% incidence in control group
-
Nonpharmacologic interventions
- Minimize catheters, IV lines, restraints
- Mobilize patient
- Monitor nutrition
- Hearing & visual aids
- Pain control
- Correct dehydration
- Address bowel & bladder issues
- Sleep-wake cycle
- Reorient patient
- Rule out infection
-
Pharmacologic intervention/prevention
- Haloperidol
- Little evidence for antipsychotics for patients with mild, non-agitated delirium
- Avoid 'unopposed' benzodiazepines
|
|