Delirium
"to leave the furrow"
Important
-Problem list, delirium itself alone cannot be billed
#Acute encephalopathy, 'cause' (delirium, 'delirum type')
-Mortality, 3y is 75% in hospitalized
Pathophysiology
-Constellation of sx suggesting global brain dysfx
-Imbalance DA vs ACh
Risk factors
-↑% → ↑age (especially >65yo)
-Medical conditions
-Medical conditions
-Modifiable: meds, immobility, metabolic disturb, poor O2
Inpatient Monitoring
CAM (Confusion Assessment Method)
-Usual screen by nurse, criteria:
1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
-Dx req: 1 + 2 + (3 or 4)
1:1
Pending
6 Dx criteria (DSM-V)
A- Attention & Awareness
B- Baseline change
C- Cognitive deficit
D- Duration
E- Etiology
F- Fluctutate
Neuro-exam
-Look for: multifocal MCL (metab disturb) & frontal release
-Mental status exam
>Orientation & attention (months backwards [<25 sec, n mistakes])
>Luria test
Classification
-Based on motor: hyperactive, hypoactive, and mixed
-Althoux hypoactive occurs 80%, does not bother, so no consults
-Check med list
>Diphenhydramine (sleep-aid) and opiates (post-op)
*Contraindication if, QTc > 500
-If no baseline, cEEG (diffuse background slow)
>POC EEG was approved for differ delirium ≠ szs
Management
-Delirium always has a cause, reverse the underlying cause!
Delirium Precautions
-Minimize sleep disturbances (lab draws, nursing care, etc), blood draws, restraints, catheterization etc as medically appropriate
-Maintain proper sleep/wake cycle (open and close shades, lights off at night)
-Frequent reorientation to place, date, and time
-Facilitate family communication/visitation as possible
-Ensure patient has glasses, hearing aids, etc
-Ensure appropriate analgesia
-Ensure appropriate fluid input and output
Prevention
- no spsfic med
>Antipsychotic do not treat delirium, do not ↓length
Sx management of agitation
-Propranolol no evidence
*For hypoactive, methylphenidate (nut no clear evidence)