Delerium

Question 1

Definition

Answer 1

AKA: acute confusional state = acute, fluctuating, clinical syndrome characterised by:
- inattention
- impaired level of consciousness
- disturbed cognitive function

Question 2

Subtypes of delerium

Answer 2

1.Hyperactive delirium: agitation or hallucinations
2. Hypoactive delirium: lethargy , reduced activity and concentration
3. Mixed delirium with symptoms and signs of both hyper- and hypoactive delirium

Question 3

Which of the subtypes of delerium is assosciated with high mortality

Answer 3

Hypoactive delerium due to being under diagnosed

Question 4

Epidemiology

Answer 4

• Advancing age
• Multiple pre-existing comorbidities: such as COPD, depression, terminal illness, catheterisation or dementia
• Cognitive impairment +/- dementia: presence of cognitive impairment increases the risk of delerium
• Severe illness: risk of deterioration
• Current hip fracture
• Increased time in hospital

Question 5

Aetiology (PINCH ME)

Answer 5

Pain
Infection - UTI
Nutrition - alcohol withdrawal
Constipation
Hydration
Medication - Benzodiazepines, opiates, antihistamines
Environment

Question 6

Precipitants which induce delerium

Answer 6

• Change in environment
• Medications and polypharmacy: e.g. benzodiazepines, opiates and some antihistamines
• Urinary retention +/- catheterisation
• Constipation
• Metabolic imbalance (e.g. hypoglycaemia, hypercalcaemia )
• Infection (UTI)
• Recent surgical procedure
  Alcohol withdrawal

Question 7

Hypoactive delerium specific signs

Answer 7

• Tiredness , slowed movements, apathy , social withdrawal
• Px may have a reduced level of consciousness

Question 8

Hyperactive delerium specific signs

Answer 8

• Restlessness , agitation, combativeness
• Patients may show inattention and distractibility

Question 9

Shared symptoms

Answer 9

• Disorganised thinking and cognitive disturbance
• Memory impairment , language disturbance
• Disorientation
• Loss of awareness of surroundings
• Lethargy
• Reversal of sleep-wake cycle

Question 10

Screening criteria

Answer 10

4AT =
- Alertness
- A MT4 (age, DOB, place, current year)
- Attention (months of the year backwards)
- Acute change or fluctuating course
NICE guidelines = recommend the short Confusion Assessment Method (short CAM) to confirm the diagnosis

Question 11

Diagnosis

Answer 11

Clinical diagnosis
Consider:
- ECG
- Urinalysis: detect hyperglycaemia or haematuria
- Urine or sputum culture
- Blood tests = FBC, Blood glucose, LFT, Bone profile, TFT,s U+E, Folate + B12, Drug levels, Inflammatory markers
- CXR: pneumonia, HF

Question 12

Treatment

Answer 12

FIRST LINE:
- Correct any precipitating factors: e.g. infection, medications, constipation, urinary retention, dehydration and pain
- Reorientation strategies: visible and accurate clocks and calendars
- Optimise treatment of co-morbidities
Consider: sedation = 0.5mg haloperidol FL

Question 13

Treatment in Parkinsons

Answer 13

• Management can be difficult, as sedating antipsychotics can worsen Parkinsonian symptoms
  A cautious reduction in Parkinson’s medication may be beneficial, otherwise, atypical antipsychotics, quetiapine and clozapine, are preferred if sedation is absolutely required

Question 14

Complications

Answer 14

Death
Falls
Increased length of stay in hospital
Cognitive impairment