DELIRIUM Presented by Dmitri Goold BScN, NP (PHC)

1. DELIRIUM Presented by Dmitri Goold BScN, NP (PHC)

2. NPSTAT Nurse Practitioners Supporting Teams Averting Transfers • CELHIN initiative to reduce unnecessary transfers from LTC to ED department • On-call service Monday- Friday 10 am-6pm • Assessments, diagnosis, treatment, health teaching, education, collaboration, supporting all members of the care team • Acute/episodic care, behavioural support (BSO), “gut feeling” • When in doubt call

3. Delirium Tell me Your Experiences

4. Delirium

6. B. Bickle, Jan 2012

7. B. Bickle, Jan 2012

8. B. Bickle, Jan 2012

9. B. Bickle, Jan 2012

11. Why do these things cause Delirium? • THEORY: Since a disorder of attention is a universal feature of confusional states, it helps to understand the neurobiology of attention. • Reticular Activating System • It is nuclei connecting Lower Brain with Upper Brain • Controls Breathing, Sleeping, Waking, Heart Rate • Connects Cortex, hypothalamus and Thalamus as well as the cranial nerves. • Use it to focus on subject. Too much focus on negative = depression • Disorder in this area cause: • Coordinate cycles/ actions: Sleep & wake, eating and sex cycles. • Consciousness • Filters stimuli (reaction to popped baloon) • Damage caused by: trauma, strokes, Meds, Chemicals, infection

12. Primary Neurotransmitter is Acetylcholine

13. Why Do We See This so often in the Elderly? • Patients with Subcortical Strokes and Basal ganglial disorders (Like Parkinson’s) have a predisposition to Delirium. Think about how the Anti-Cholinergic Gravol Makes you Feel • Anticholinergic drugs cause delirium when given to healthy volunteers and are even more likely to lead to acute confusion in frail elderly persons.  Conditions such as hypoxia, hypoglycemia, and thiamine deficiency, decrease acetylcholine synthesis

14. Other Causes Cytokine activation may account for delirium (particularly hyperactive forms of the disturbance) in situations such as sepsis (where mental changes may actually precede fever identified risk factors are underlying brain diseases such as dementia, stroke, or Parkinson disease; these are present in nearly 50% of older patients with delirium Other factors that increase the vulnerability to delirium include advanced age and sensory impairment Some common examples include polypharmacy (particularly psychoactive drugs), infection, dehydration, immobility (including restraint use), malnutrition, and the use of bladder catheters.

15. Recap, What you will See: memory loss, disorientation, and difficulty with language and speech. Formal mental status testing can be used to document the degree of impairment, Patients may misidentify the clinician or believe that objects or shadows in the room represent a person. Vague delusions of harm often accompany these misperceptions. Hallucinations can be visual, auditory or somatosensory, usually with lack of insight - the patients believe they are real. A variety of language difficulties can occur. Patients may lose the ability to write or to speak a second language Delirium develops over hours to days and typically persists for days to months the features of delirium are unstable, typically becoming most severe in the evening and at night

16. PEARL cognitive change in Alzheimer disease is typically insidious, progressive, without much fluctuation, and occurs over a much longer time (months to years). Attention is relatively intact, as are remote memories in the earlier stages ■Dementia with Lewy bodies (DLB) is similar to Alzheimer disease but can be more easily confused with delirium, because fluctuations and visual hallucinations are common and prominent

17. Delirium