CDM 4 Exam 2 Review Evaluation of Consciousness Delirium and Dementia I Identify the various stages of consciousness in a patient admitted to the intensive care unit ICU using a validated assessment tool such as the Riker sedation agitation scale SAS A Consciousness a deeper level of sedation is observed as you go down this list 1 Severe agitation very dangerous 2 Moderate agitation 3 Calm and awake this is the ideal goal for most patients B Riker sedation agitation scale SAS 4 Sleepy 5 Deep Sleep 6 Unarousable 7 Coma very dangerous 1 7 Dangerous Agitation Pulling at endotracheal tube trying to remove catheters climbing over bedrail striking at staff thrashing side to side 2 6 Very Agitated requiring restraint and frequent verbal reminding of limits biting 3 5 Agitated anxious or physically agitated calms to verbal instructions 4 4 Calm and cooperative Calm easily arousable follows commands 5 3 Sedated difficult to arouse but awakens to verbal stimuli or gentle shaking follows simple 6 2 Very Sedated arouses to physical stimuli but does not communicate or follow commands 7 Coma Unarousibility minimal or no response to noxious stimuli does not communicate or commands but drifts off again may move spontaneously follow commands C Guidelines for SAS assessment 1 Agitated patients are scored by their most severe degree of agitation as described 2 If patient is awake or awakens easily to voice awaken means responds with voice or head shaking to a question or follows commands that s a SAS 4 same as calm and appropriate might even be napping If more stimuli such as shaking is required but patient eventually does awaken that s a SAS 3 If patient arouses to stronger physical stimuli may be noxious but never awakens to the point of responding yes no or following commands that s a SAS 2 5 Little or no response to noxious physical stimuli represents a SAS 1 6 NOTE this helps separate sedated patients into those you can eventually wake up SAS 3 3 4 those you can t awaken but can arouse SAS 2 and those you can t arouse SAS 1 II Differentiate delirium from dementia A Delirium very common in hospitalized patients ICU elderly vs nonelderly elderly cardiac or hip fracture surgery medical floor admin elderly vs nonelderly 1 Many risk factors most are NOT modifiable 2 Not modifiable Risk factors a Patient factors age alcohol use male gender living alone smoking renal disease b Predisposing disease cardiac disease cognitive impairment ex dementia pulmonary disease 3 Modifiable Risk Factors a Environment Admission via ED or through transfer isolation no clock no daylight no visitors noise use of physical restraints b Acute Illness length of stay fever medicine service lack of nutrition hypotension sepsis metabolic disorders tubes catheters medications anticholinergics corticosteroids benzodiazepines 4 DSM IV Criteria for Delirium NOTE can only be used by a board certified psychiatrist to clinically identify delirium 1 a Disturbance of consciousness with reduced ability to focus sustain or shift attention b A Change in cognition or the development of perceptual disturbance that is not better accounted for by a pre existing established or evolving dementia c The disturbance develops over a short period of time and tends to fluctuate during the course of the day d There is evidence from the history PE or labs that the disturbance is caused by the direct physiologic consequences of a general medical condition B Dementia loss of brain function that occurs with certain diseases It affects memory thinking language judgment and behavior 1 Common Causes Alzheime s Parkinson s MS CNS infections CNS tumors Delirium 2 S sx associated with moderate sever dementia a Forgetting details about current events b Forgetting events in your own life history losing awareness of who you are c Change in sleep patterns often waking up at night d More difficulty reading or writing e Poor judgment and loss of ability to recognize danger f Using the wrong word not pronouncing words correctly speaking in confusing g Withdrawing from social contact h Having hallucinations arguments striking out and violent behavior i Having delusions depression agitation j Difficulty doing basic tasks such as preparing meals choosing proper clothing or sentences driving III Identify delirium in a verbal patient outside the ICU using the confusion assessment method CAM A Confusion Assessment Method CAM outside the ICU when patient is likely to talk gold standard method to screen for delirium by non psychiatric personnel it is not feasible for a psychiatrist to be available to screen patients for delirium ex q12hr in the hospital setting therefore the primary role for the screening of delirium in the hospital falls to the bedside RN but pharmacists can play a HUGE role in delirium screening B delirium diagnosis by CAM requires the presence of features 1 and 2 and either 3 or 4 1 Acute onset this feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions Is there evidence of an acute change in mental status from the patient s baseline Did the abnormal behavior fluctuate during the day that is tend to come and go or increase and decrease in severity 2 Inattention this feature is shown by a positive response to the following question did the patient have difficulty focusing attention for example being easily distractible or having difficulty keeping track of what was being said 3 Disorganized thinking This feature is shown by a positive response to the following question Was the patient s thinking disorganized or incoherent such as rambling or irrelevant conversation unclear or illogical flow of ideas or unpredictable switching from subject to subject 4 Altered level of consciousness this feature is shown by an answer other than alert to the following question Overall how would you rate this patient s level of consciousness a Alert normal vigilant hyperalert lethargic drowsy easily aroused stupor difficult to arouse or coma unarousable IV Identify delirium in a non verbal patient in the ICU using both the confusion assessment for the ICU and the intensive care delirium screening checklist ICDSC 2 EITHER 3 or 4 A Confusion assessment method for the intensive care unit CAM ICU must have 1 and 2 and 1 Acute onset or fluctuating mental status different from baseline or sedation score fluctuation over 24 hr SAS the CAM ICU cannot be completed if patient is deeply sedated SAS of 2 or 1 2