[Geriatrics] Confusion

Question 1

what is delirium?

Answer 1

an acute confusional state

Question 2

what is delirium characterised by?

Answer 2

• disturbances in consciousness, cognitive function or perception
• acute in onset with a fluctuating course

Question 3

what is essential in assessing delirium?

Answer 3

collateral hx

Question 4

pts with predisposing factors are at an increased risk of developing delirium. what are the predisposing risk factors?

Answer 4

• older age (>65 years)
• cognitive impairment
• frailty / multiple co-morbidities
• significant injuries e.g. hip fracture
• functional impairment
• iatrogenic (surgery, medications, catheterisation)
• sensory impairment
• poor nutritional status
• lack of stimulation
• terminal illness
• alcohol intoxication / withdrawal

Question 5

causes of delirium are often…?

Answer 5

multifactorial

Question 6

delirium is associated with…?

Answer 6

significant morbidity and mortality

Question 7

how may delirium present as?

Answer 7

• hypoactive
• hyperactive
• mixed

Question 8

what are features of hypoactive delirium?

Answer 8

• lethargy
• reduced movement
• lack of interest in daily activities
• quiet and withdrawn

if severe, can cause a reduced GCS

Question 9

what are features of hyperactive delirium?

Answer 9

• increased sensitivity to surroundings
• agitation
• restlessness
• sleep disturbance
• hyper-vigilance

Question 10

what are features of mixed delirium?

Answer 10

combination of hyper and hypoactive delirium

Question 11

how is a Dx of delirium made?

Answer 11

based on DSM-IV or the short Confusion Assessment Method (short-CAM)

Question 12

what is the DSM IV criteria for diagnosing delirium?

Answer 12

need all 4 of:

1. confusion which is new and fluctuating
2. altered consciousness
3. change in cognition
4. evidence from hx/ex/ix which cannot be attributed to another condition

Question 13

what is the short-CAM criteria for diagnosing delirium?

Answer 13

need 1+2+3/4:

1. confusion which is new and fluctuating
2. inattention
3. disorganised thinking
4. altered consciousness

Question 14

delirium vs dementia vs depression: consciousness

Answer 14

delirium - altered
dementia - normal
depression - normal

Question 15

delirium vs dementia vs depression: onset

Answer 15

delirium - acute
dementia - chronic
depression - chronic

Question 16

delirium vs dementia vs depression: fluctuation

Answer 16

delirium - yes
dementia - no (except Lewy Body)
depression - no

Question 17

delirium vs dementia vs depression: reversible

Answer 17

delirium - yes, recovery may take several months
dementia - no
depression - yes

Question 18

delirium vs dementia vs depression: treatment

Answer 18

delirium - treat underlying cause
dementia - acetylcholinesterase inhibitors or memantine
depression - antidepressants

Question 19

delirium vs dementia vs depression: legal framework to treat if unable to consent/risk

Answer 19

delirium - Mental Capacity Act
dementia - Mental Capacity Act, Mental Health Act
depression - Mental Health Act

Question 20

visual hallucinations + macular degeneration. dx?

Answer 20

Charles Bonnett syndrome

Question 21

Parkinsonism, visual hallucinations and memory impairment. dx?

Answer 21

Lewy-Body dementia

Question 22

deranged LFTs, asterixis and confusion. dx?

Answer 22

hepatic encephalopathy

Question 23

what are the precipitating causes of delirium?

Answer 23

DELIRIUM:
D - drugs, dehydration, detox, deficiencies, discomfort (pain)
E - electrolytes, elimination abnormalities, environment
L - lungs (hypoxia), liver, lack of sleep, long ED stay
I - infection, iatrogenic events, infarction (cardiac, cerebral)
R - restraints, restricted movement/mobility, renal failure
I - injury, impaired sensory input, intoxication
U - UTI, unfamiliar environment
M - metabolic abnormalities (glucose, thyroid), metastasis (brain), medications