What are the 4 parts of 4AT?
- Alertness
- AMT4
- Attention
- Acute change or fluctuating course
What is the scoring of alertness in 4AT?
Patients who are markedly drowsy (e.g. difficult to rouse and/or obviously sleep during assessment) or agitated/hyperactive. Ask patient to state their name and address to assist rating.
- Normal (fully alert/not agitated) 0
- Mild sleepiness for <10 secs after waking then normal 0
- Clearly abnormal 4
What is the scoring of AMT4 in 4AT?
Age, DOB, place (name of hospital/building), current year
- No mistakes 0
- 1 mistake 1
- 2 or more mistakes/untestable 2
What is the scoring of attention in 4AT?
Ask the patient to name the months in order backwards from December. Initial prompt of telling them to start at December is allowed.
- Achieves 7 or more correctly 0
- Starts but scores <7 months/refuses to start 1
- Untestable (cannot start as unwell/drowsy/inattentive) 2
What is the scoring of acute change/fluctuating course in 4AT?
Evidence of significant change or fluctuation in alertness, cognition, other mental function (e.g. paranoia, hallucinations), arising over the past 2 weeks and still evident in the last 24 hours.
- No 0
- Yes 4
What does the total score of 4AT tell us?
4 or above: possible delirium +/- cognitive impairment
1-3: possible cognitive impairment
0: delirium or severe cognitive impairment unlikely but not ruled out
What is anticholinergic burden?
Refers to the cumulative effect of all the drugs a patient is on which possess anticholinergic effects and takes into consideration both the number of such drugs as well as the individual potencies of each drug. A score of 3+ is associated with increased cognitive impairment and mortality.
What are the side effects of anticholinergic drugs?
They have long been associated with ADRs including urinary retention, drowsiness, dry mouth and constipation.
What are the risk factors for delirium?
PINCH ME
- Pain
- Infection
- Nutrition
- Constipation (+/- urinary retention)
- Hydration
- Medication e.g. also electrolyte imbalances
- Environment
What are the other risk factors for delirium not in the PINCH ME acronym?
- Dementia (progressive cognitive decline)
- Previous delirium episodes
- Advancing age
- Hip fracture
- Polypharmacy
What are general measures for delirium?
- Offer reassurance and try to re-orientate the patient at each opportunity - where they are, what time
- Encourage mobility
- Try to promote normal sleep-wake cycle e.g. stop nocturnal interventions, keep lights off
- Encourage oral intake of food and fluids (e.g. missing dentures)
- Regulation of bladder and bowel function
- Minimise sensory impairment by getting their glasses/hearing aids
- Encourage family/friends to visit and help support re-orientation and reassurance
- Review medications/check for withdrawal
- Pain control
- Prevention, early identification and treatment of postoperative complications
What is the Confusion Assessment Method (CAM)?
Delirium is likely to be present if there is:
1. Presence of acute confusion, with fluctuation
AND
2. Inattention (difficulty concentrating)
AND EITHER
3. Disorganised thinking
OR
4. Altered level of consciousness i.e. heightened arousal/agitation or drowsy
In what circumstances can pharmacological therapy be considered for delirium?
- To prevent the patient endangering themselves or others
- To allow staff to carry out essential investigations or treatment
- To relieve stress in highly agitated patients, particularly those with paranoia or hallucinations
- Non-pharamacological measures have failed
- The patient should have their capacity assessed as to whether they are agreeable to sedation
- DoLS should be completed at this stage if they do not have capacity to consent for sedation
What are the contraindications for haloperidol?
- QTc interval on the ECG
- Parkinson’s
- Lewy Body dementia
- Hx of Torsade de pointes, ventricular arrhythmia or recent cardiac event (MI or decompensated HF)
- Cannot be used alongside any medication that causes prolonged QT interval
What are the contraindications for risperidone?
- Parkinson’s
- Lewy Body Dementia
- Can cause prolongation of QTc interval so ECG should be done prior to ensure it is normal
- This is off licence for delirium
What are the contraindications for lorazepam?
- Risk of respiratory depression
- Falls
- Deliriumogenic
- Exercise caution in renal impairment
- Off licence for delirium
What is the pharmacological treatment for delirium?
1st line: low dose haloperidol short-term (1 week or less) - 0.5-1mg PO (max 2mg/24hr)
2nd line: low dose lorazepam if haloperidol contraindicated
Which tools should be used for detecting delirium in different settings?
- 4-AT tool should be used in A+E, acute hospital settings and the community
- In intensive care settings CAM-ICU or ICDSU should be considered to help identify possible delirium.
When should a CT head be done in delirium?
- New focal neurological signs
- A reduced level of consciousness (not adequately explained by another cause)
- A hx of recurrent falls
- A head injury (patients of any age)
- Anticoagulation therapy
When should an EEG be done in delirium?
When there is suspicion of epileptic activity or non-convulsive status epilepticus as a cause of a patient’s delirium.
What are the non-pharmacological stages for delirium treatment?
- Consider acute life threatening causes e.g. low O2, low BP, low glucose, drug/alcohol intoxication/withdrawal
- Identify and treat potential causes e.g. medications
- Management of concurrent conditions, environment (reduce noise), medications, sleep
- Detect, asses causes of and treat agitation +/or distress
- Communicate diagnosis to family/carers and encourage involvement
- Aim to prevent complications e.g. immobility, falls, isolation
- Monitor for recovery consider specialist referral
- Consider follow-up
What are the 5 overarching principles of the Mental Capacity Act (2005) and DoLS?
- A person is assumed to have capacity unless it is established they do not
- A person is not to be treated as unable to make a decision unless all steps to help him have been taken without success
- A person is not to be treated as unable to make a decision merely because they make an unwise one
- An act/decision on behalf of a person who lacks capacity must be done in their best interests
- Before the act is done/decision made, regard must be had to whether the purpose for it being needed can be effectively achieved in a way that is least restrictive of the person’s rights/freedom
How do you assess capacity?
- Is there an impairment of, or a disturbance in the functioning of, the mind or brain?
- The Act states that someone lacks the capacity to make a specific decision if the answer to 1 is yes and they are unable to do 1 or more of the following:
- Understand the info relevant to the decision
- Retain that information
- Use or weigh up that information as part of the process of making the decision
- Communicate their decision
What are commonly missed causes of delirium?
- Urinary retention
- Constipation
- Pain
