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Delirium

QuestionAnswer
Delirium DSM 5 TR Criteria disturbance in attention accompanied by reduced awareness of environment develops over short time period (hours - days), change from baseline, fluctuates in severity throughout day additional disturbance in cognition not better explained by other
Specifiers for Delirium Acute (few hours/days) vs Persistent (weeks/months) Hyperactive (mood lability, agitation, uncooperative) or Hypoactive (sluggishness, lethargy, stupor) or mixed level (normal psychomotor activity with fluctuating attention and awareness)
Additional Specifiers for Delirium Substance intoxication Substance withdrawal Medication induced Due to another medical condition Due to multiple etiologies
Hyperactive (Level of Activity) Agitated state of mind: aggression and restlessness -substance or withdrawal common higher detection rate - better outcomes can be misdiagnosed as intoxication or psychotic disorder
Hypoactive (Level of Activity) Apathetic state of mind: lethargy, depression, stupor -metabolic causes or organ failure more common in older adults poorer prognosis than hyperactive misdiagnosed often as depression or normal stress response to acute illness
Mixed (Level of Activity) Shifting from hyperactive to hypoactive normal activity with disturbed attention/awareness generally poorer prognosis than hyperactive
Risk Factors Elderly >65 yr Males Pre-existing/underlying neurocog - Stroke/dem Surgical Substance use Medications - opioids, benzo, corticosteroids, dopamine agonists
Other risk factors Infection Dehydration Immobility Malnutrition Urinary Catheterization Sensory Impairment
Negative Outcomes Increasing length of hospital stay increasing risk of morbidity and mortality increased stress for client and caregiver
Delirium in Children Prevalence 10-30% critically ill poor outcomes - trauma sx, increase hospitalization, delusional memories
Children's risk factors for Delirium < 2 yrs infection or inflammation disorder mechanical ventilation restraint use PICU stay > 5 days Meds - vasopressors, anti-epileptics, narcotics, sedatives, steroids
Delirium Course Full recovery higher risk - poorer outcomes even after recovery, including dementia and need for admission to an institution progression to coma or death if untreated
Labs and Tests Blood Chemistries - Electrolytes/renal/hepatic/glucose, CBC w/ diff, TSH, UA, UTox, Syphillis/HIV, Cultures - Sputum, blood, CSF, urine, B12/Folic Acid Chest XR, EKG, EEG, NeuroImaging
Assessment Tools for Adults CAM CAM-ICU Observational Scale of Level of Arousal
Interventions for Delirium Non-Pharm 1st Choice Safety precautions Restraints - only if absolutely necessary Sensory aids - HA, glasses Environmental Interventions Help with feeding/elimination needs Pain assessment/management
Safety Precautions Frequent rounding Fall precautions 1:1 sitter
Environmental Interventions Lighting Clocks/Calendars Photos
Pharmacological Interventions for Delirium in the Hospitalized Older Adult Antipsychotics for acute agitation/perceptual disturbance Benzodiazepines (limited use - withdrawal) Dexmedetomidine (high cost factor) Melatonin (not well studied)
Antipsychotics for acute agitation/perceptual disturbances most commonly prescribed agent Caution in patients with lewy body dementia (VH) Haloperidol - low anticholinergic profile - IV Monitor EKG Risperidone - most studies SGA If doesn't work - agitation continues or worsens, consider akathisia
Akathisia The inability to remain still Neuropsychiatric syndrome associated with psychomotor restlessness inner restlessness and mental distress
Created by: akimball80
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