delirium.ppt haja jajal sons uk meu hia h

The diagnosis of stroke involves a combination of clinical evaluation, imaging studies, and laboratory tests. Here are the key steps in diagnosing a stroke:

1. *Clinical Evaluation*:
- Medical history
- Physical examination (neurological exam)
- Assessment of vital signs (blood pressure, pulse, temperature, etc.)
2. *Stroke Scales*:
- National Institutes of Health Stroke Scale (NIHSS)
- Glasgow Coma Scale (GCS)
3. *Imaging Studies*:
- *Computed Tomography (CT) Scan*: Non-contrast CT scan to rule out hemorrhage
- *Magnetic Resonance Imaging (MRI)*: Diffusion-weighted imaging (DWI) to confirm ischemic stroke
- *Computed Tomography Angiography (CTA)*: To evaluate blood vessels
4. *Laboratory Tests*:
- Complete Blood Count (CBC)
- Electrolyte panel
- Renal function tests
- Lipid profile
- Blood glucose level
5. *Other Tests*:
- Electrocardiogram (ECG) to rule out cardiac arrhythmias
- Echocardiogram to evaluate cardiac function
- Carotid duplex ultrasound to evaluate carotid artery stenosis

The goal of prompt diagnosis is to determine:

- Whether the stroke is ischemic or hemorrhagic
- The location and severity of the stroke
- The underlying cause of the stroke
- The appropriate treatment strategy

Note: The American Heart Association/American Stroke Association recommends the "FAST" mnemonic to recognize stroke symptoms:

F - Face: Ask the person to smile. Does one side of their face droop?

A - Arm: Ask the person to raise both arms. Does one arm drift downward?

S - Speech: Ask the person to repeat a simple sentence. Is their speech slurred or difficult to understand?

T - Time: Time is of the essence. Call for emergency medical services immediately if you observe any of these symptoms.
The diagnosis of stroke involves a combination of clinical evaluation, imaging studies, and laboratory tests. Here are the key steps in diagnosing a stroke:

1. *Clinical Evaluation*:
- Medical history
- Physical examination (neurological exam)
- Assessment of vital signs (blood pressure, pulse, temperature, etc.)
2. *Stroke Scales*:
- National Institutes of Health Stroke Scale (NIHSS)
- Glasgow Coma Scale (GCS)
3. *Imaging Studies*:
- *Computed Tomography (CT) Scan*: Non-contrast CT scan to rule out hemorrhage
- *Magnetic Resonance Imaging (MRI)*: Diffusion-weighted imaging (DWI) to confirm ischemic stroke
- *Computed Tomography Angiography (CTA)*: To evaluate blood vessels
4. *Laboratory Tests*:
- Complete Blood Count (CBC)
- Electrolyte panel
- Renal function tests
- Lipid profile
- Blood glucose level
5. *Other Tests*:
- Electrocardiogram (ECG) to rule out cardiac arrhythmias
- Echocardiogram to evaluate cardiac function
- Carotid duplex ultrasound to evaluate carotid artery stenosis

The goal of prompt diagnosis is to determine:

- Whether the stroke is ischemic or hemorrhagic
- The location and severity of the stroke
- The underlyi

1. Doctor of physical therapy
Delirium

2. Delirium
Definition:
A disturbance of
consciousness
with inattention
that develops
over a short
time &
fluctuates

3. What is Delirium?
•An acute confusional
state
•Usually has a
reversible cause
•Characterized by:
–Inattention
–Sudden onset
–………………..

4. Why Should We Use Delirium
Guidelines ?
•Delirium can result in:
– morbidity and mortality
– length of stay
– rates of admission to long term care
facilities
–20% of patients discharged post hip # still
had evidence of delirium (Journal of American Geriatric
Society 2001 May;49(5):678-9).

5. 40%
25%
35%
RecoveryPermanent Cognitive ImpairmentMortality
Outcomes of Delirium
(even with complete recovery, 30% dementia within 3 years =
decreased brain reserve)

6. Recognition of Delirium
•Previous studies 32%-66% of cases are
unrecognized by Medical Staff
Yale- New Haven study (Inouye S. Ann Intern Med 1993: 119-474)
–65% unrecognized by Physicians
–43% unrecognized by Nurses

7. Top 4 Independent Risk Factors for
Delirium
Vision impairment:
Any severe illness:

Cognitive impairment :
High Urea/Creatinine
ratio:
Inouye S. Ann Intern Med 1993: 119-474

8. 4 Independent Risk Factors for Nurse
Under-Recognition
•Hypoactive Delirium
•Age 80 yrs and over
•Visual Impairment
•Dementia

9. Types of Delirium
•Hyperactive
•Hypoactive
•Mixed

10. Causes of Delirium?
•Anything that hurts the brain or impairs its
proper functioning can provoke a delirium!
•Brain’s way of demonstrating “acute organ
dysfunction”

11. Causes of Delirium:
1.Drugs
2.Infection
3.System failure/events
4.Metabolic Imbalance
5.Dehydration/Poor Nutrition
6.Surgery or general anaesthetic within the
last 5 days

12. Causes of Delirium:
7.Pain
8.Uncorrected sensory or
language impairment
9.Fecal Impaction
10.Urinary Retention/Catheter
11.Restraints
12. Sleep disruption
13. No factors can be identified
20% of the time
14. Recent severe illness or event
involving hypoxia

13. Causes of Delirium Related to Surgery
Risk Factors
Predisposing
Precipitating
Comorbidities
Diabetes
MI
Etc…
Perioperative
Drugs
Anesthetics
 Opioids
 Benzodiazepines
Etc…

14. Theories for Post Op Delirium
•Acetylcholine interaction with medications
used during surgery
•Increase of neurotransmitters, serotonin and
dopamine during surgery
•Previous abnormality levels of melatonin
•Damage to neurons by oxidative stress or
inflammation caused by a surgical procedure
•Post op abnormal brain waves

15. •Any drug can potentially cause confusion
•Take a careful history of any new drug
STARTED or any old drug STOPPED
recently
Medications Associated with
Delirium

16. Medications Associated with
Delirium
•Over the counter
drugs
–Cimetidine
–Cough/Cold Remedies
–Gravol/Maxeran
–Sleeping medications
–Herbal meds

17. Reference List of Drugs with
Anticholinergic Effects
•Antidepressants
•Antipsychotics
•Antihistamines/
Antipruritics
•Antiparkinsonian
•Antispasmotics
•Antiemetics
•Opioids
•Anticonvulsants
•Antibiotics
•Corticosteroids
•Anticholinergics

18. Studies
In studies, drugs with anti cholinergic side effects have been
shown to:
•Lower cognitive scores in elderly subjects
•Cause/worsen severity of delirium
•Associated with more ADL decline in patients with dementia
•Associated with faster MMSE(Mini–mental state examination
) decline in patients with dementia
•If drugs reduced, be associated with improvements in
dementia and delirium.

19. Assessing for Delirium

20. CAM – Confusion Assessment Method
–Sensitivity (94 to 100%), specificity (90 to 95%)
Requirement for delirium = 1, 2 AND either 3 OR
4
1.Abrupt change?
2.Inattention, can’t focus?
3.Disorganized thinking? Incoherent, rambling,
illogical?
4. Altered level of consciousness? (Hyper-alert to
stupor?)
AND

21. Trigger Questions
1. Acute change in behaviour?
2. Changes in function?
3. Changes in cognition? MMSE
4. Changes in medications?
5. Physiologically stable?

22. How Do We Assess for Inattention
•Recite the months backwards or days
backwards
•Have the patient count backwards from
20 to 1.
•Use the CAM

23. Once You Identify Delirium, Now
What?
•Identify the acute medical problems that
could be either triggering the delirium, or
prolonging it!
•Clarify pre-morbid functional status,
sequence of events and previous admission
cognitive baseline
•Identify all predisposing and precipitating
factors, and consider the differential

24. Physical Exam
–Vitals: normal range of BP, HR, Temp and pain

–Good physical exam: particular emphasis on
Cardiac, pulmonary and neurologic systems
–Hydration status
–Also rule out
•fecal impaction
•urinary retention
•Infected pressure ulcer, UTI or pneumonia

25. Delirium workup: Lab testing
•Basic labs most helpful!
–CBC, lytes, BUN/Cr,
glucose,CO2, Ca+, Mg,
PO4
–TSH, B-12, LFTs & albumin
•Infection workup
(Urinalysis, CXR) +/- blood
cultures
•EKG
•O
2 sat/ABG

26. What About Prevention?

27. Yale Delirium Prevention Trial
Risk Factors Intervention
Cognitive Impairment Reality orientation / therapeutic
activities program
Vision/Hearing impairmentVision / hearing aids / adaptive
equipment
Immobilization Early mobilization / Reduce
immobilizing equipment
Psychoactive medicationNon pharmacologic approaches to
sleep / anxiety / Restricted use of sleeping medication
Dehydration Early recognition / Volume
expansion
Sleep deprivation Noise reduction strategies/sleep
enhancement program
Ref: Inouye SK, NEJM. 1999;340:669-676

28. What about Management?

29. Non Pharmacological Interventions
•Always apply non-pharmacological
interventions in your Care Plan. Examples
–Initiate toileting routines
–Mobilize ASAP
–Quiet room, soothing music

30. Pharmacological Interventions
•Only use medication if:
–Non-pharmacological interventions are not
successful
–The patient is a danger to themselves or others
•You may see the physician order or a pharmacist
suggest the following medications:
–Low dose Haloperidol or
–Low dose Risperidone or
–Low dose Olanzapine
–** Avoid the use of benzodiazepines

31. Delirium Pamphlet
•This is to be given to Families so that they may
better understand what their family member
is going through.
•It is also recommended that it be displayed in
any Pamphlet Holders for Patient and Family
Education.

32. Questions ??????