Basic of Geriatrics and Internal Medicine for Physiotherapist by Rasheedy D - HTML preview

Delirium (Acute Confusional State)

Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment (inattention), and altered level of consciousness.. The start of delirium is usually rapid — within hours or a few days.

Causes

Drugs: sedatives, anticholinergic drugs, drug withdrawal

Infection (eg: chest infection, urinary tract infection)

Urine retention– Fecal impaction

Metabolic: hypoglycemia-hyperglycemia, end organ disease (uremia, hepatic encephalopathy, respiratory failure)

Electrolytes disturbance: ↓ Na, Ca

Myocardial infarction(MI)

Pain

Clinical picture: ACUTE ONSET, FLUCTUATING COURSE, SECONDARY TO MEDICAL condition, INATTENTION, DISORGANIZED THINKING (The Confusion Assessment Method CAM)

1. Inattention:

inability to stay focused on a topic or to switch topics

inability to stay focused on a topic or to switch topics

2. Altered consciousness:

Increased; irritability and excitability

Decreased; apathy, decreased consciousness and decreased response to stimuli

3. Cognitive impairment

Poor memory, particularly of recent events

Disorientation — for example, not knowing where he is

Rambling or nonsense speech

Trouble understanding speech

4. Neuropsychiatric findings;

Hallucinations

Illusions

Delusions

Emotional distress

sleep disturbances

Types: hyperactive, hypoactive, mixed

Hyperactive delirium. Probably the most easily recognized type, this may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations, and refusal to cooperate with care.

Hypoactive delirium. This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness, or seeming to be in a daze.

Mixed delirium. This includes both hyperactive and hypoactive signs and symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states.

Complications delirium:

1. Iatrogenic complications (eg: antipsychotic use, mechanical constraints)

2. Incontinence

3. Complications of bed ridden (eg: deconditioning, pressure ulcers, aspiration)

4. Malnutrition

5. Hospitalization

6. Long-term care admission

7. Falls

8. Functional decline

Management of delirium:

1. Identify and remove or treat underlying cause (may be life threatening MI, hyponatremia)

2. Provide general supportive measures:

• • Keep patient in quiet, well-lit room (eg, night lights)
  • Ensure safe environment and strict supervision
  • Avoid excessive noise, stimulation
  • Reorientation:

Encourage familiar faces (family members) at bedside for reassurance

Provide orientation (eg, calendar, clock)

Correct sensory impairment (eg, vision, hearing)

• • Nutrition and good hydration
  • Enhance mobility and range of motion
  • Care of bowel and bladder

3. Control of disruptive behavior

• • Use physical restraints only as last resort to maintain patient safety (eg, prevent patient from pulling out tubes, catheters)
  • For acute agitation or aggression: use a high-potency antipsychotic such as haloperidol (Haldol) 0.5-2mg po or IM.

Role of physical therapy in prevention and management of delirium:

• • Early mobilization and walking following surgeries
  • Minimizing use of immobilizing equipment
  • Individual active mobilization strongly encouraged, Progress through range-of-motion, sitting, standing, walking, ADLs
  • Assisted walking for frail patients routinely performed by PT

Delirium and dementia

Dementia and delirium may be particularly difficult to distinguish, and a person may have both. In fact, delirium frequently occurs in people with dementia. But having episodes of delirium does not always mean a person has dementia. So a dementia assessment should not be done during a delirium episode because the results could be misleading.

Dementia is the progressive decline of memory and other thinking skills due to the gradual dysfunction and loss of brain cells. The most common cause of dementia is Alzheimer's disease.

Some differences between the symptoms of delirium and dementia include:

Onset. The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time.

Attention. The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert.

Fluctuation. The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day.

Because symptoms of delirium and dementia can be similar, input from a family member or caregiver may be important for a doctor to make an accurate diagnosis.