Delerium

Question 1

What is the definition of delerium?

Answer 1

A syndrome of acute, fluctuating change in mental status, with inattention, disorganised thinking, and altered levels of consciousness. It is a potentially life-threatening disorder characterised by high morbidity and mortality.

Question 2

What is the general prevalence of delerium in the in-patient population?

Answer 2

20-30%

Question 3

What is important to remeber about confusion in terms of its association with a delerium?

Answer 3

It is a symptom of muddled thinking, which is not confined solely to delerium, and can be present in depression, dementia and psychotic disorders.

It is presentation, not a diagnosis

Question 4

What are the features of delerium?

Answer 4

• Disordered thinking - slow irrational rambling, jumbled up, incoherent ideas
• Euphoric/fearful/depressed/angry - labile mood, anxious then torpid
• Language impairment - speech reduced or gabbling, repetitive, disruptive
• Illusions/delusions/hallucinations - tactile or visual (auditory suggests psychosis)
• Reversal circadian rhythm
• Inattention - focusing is poor, no real dialogue
• Unaware/disorientated - doesn’t know own name, or location
• Memory deficits

Question 5

What are the features hyperactive delerium?

Answer 5

• Oversensitive to stimuli
• Psychomotor stimulation
• Noisy
• Psychotic
• Aggressive

Question 6

What are the 3 key features of delerium?

Answer 6

• Disturbed consciousness
  
  • Hypoactive/hyperactive/mixed
• Change in cognition
  
  • Memory/perceptual/language/illusions/hallucinations
• Acute onset and fluctuant

Question 7

What can cause delerium?

Answer 7

• Infection
• Drug intoxication
• Disorders of electrolyte/fluid balance - dehydration, uraemia
• Alcohol/drug withdrawal
• Organ failure - cardiac, respiratory, liver
• Hypo/hyperglycaemia
• Epilepsy
• Intracranial pathology- stroke, tumour, bleed
• Pain
• Constipation/urinary retention

Question 8

What medications can cause delerium?

Answer 8

• Anticholinergics
• Antipsychotics
• Antihistamines
• Anxiolytics - barbituates, benzodiazepines
• Antidepressants
• Anticonvulsants
• Opaites
• Corticosteroids
• Lithium
• H2 receptor blockers
• L-Dopa
• Digoxin

Question 9

What recreational drugs can cause delerium?

Answer 9

• Alcohol
• Marijuana
• LSD
• Amphetamines
• Cocaine
• Opiates

Question 10

How would you approach assessing a patient with delerium?

Answer 10

• History
• Collateral History
• Examination
• 4AT/AMTS/MMSE

Question 11

What is the 4AT?

Answer 11

Rapid assessment for delerium which includes the month backwards test and the abbreviated mental test 4.

It is used to asses for moderte to severe cognitive impairment, and for delerium

Question 12

What investigations would you do if someone presented with delerium?

Answer 12

Based on TIME bundle

• Bloods - FBC, ESR, TFTs, U+Es, Glucose, CRP, Calcium and phosphate
• CXR
• ECG
• Urinalysis + culture
• Blood cultures
• Blood gases

Question 15

What tests would you do to asses for infection as a cause for delerium?

Answer 15

• Bloods - FBC, ESR, CRP
• Blood culture
• CXR
• Urinalysis and culture

Question 16

How would you assess for dehydration as a cause of delerium?

Answer 16

Bloods - U+Es

Question 17

What is a TIME Bundle?

Answer 17

A tool used for guiding assessment and management of someone with delerium

Question 18

How would you assess abnormal blood sugar as a cause of delerium?

Answer 18

Finger prick blood test

Bloods - Glucose

Question 19

How would you assess hypoxaemia or hypercapnia as contributory causes of delerium?

Answer 19

Blood gases

Question 21

What non-pharmacological measures would you use to manage someone with delerium?

Answer 21

• Re-orientate and reassure agitated patients - USE FAMILIES/CARERS
• Encourage early mobility and self-care
• Correction of sensory impairment
• Normalise sleep-wake cycle
• Ensure continuity of care
• Avoid urinary catheterisation/venflons

Question 22

When would pharmacological measures be used to manage someone with delerium?

Answer 22

If the patient becomes agitated leading them to become a danger to themselves or others, or to interfere with medical treatement (e.g. cannulas)

Question 23

What medications could you use for an agitated delerious patient?

Answer 23

Single drug or combination of:

• Short-acting benzodiazepines - lorazepam
• Typical antipsychotics - haloperidol
• Atypical antipsychotics - olanzapine, risperidone, quitiepine

Question 24

What should you remember when administering medications to an agitated delerious patient?

Answer 24

Start low and go slow, and use for as short a period as possible

Question 25

Who are most at risk of developing delerium?

Answer 25

• Old individuals taking multiple medicines
• Demented
• Dehydrated
• Infected
• Surgical patients - esp hip
• Poor sight and hearing
• Constipated
• Urinary retention

Question 26

What is important to remember about delerium in terms of the cause?

Answer 26

It is often because of multiple precipitants

Question 27

What are features of hypoactive delerium?

Answer 27

• Psychomotor retrdation
• Lethargy
• Quiet
• Paucity of speech
• Few hallucinations

Question 28

What is the defintion of capacity?

Answer 28

Ability to understand information relevant to a decision or action and to appreciate the reasonably forseeable consequences of taking or not taking that action or decison

Question 29

What are the steps to assesing capacity?

Answer 29

1. **Presume capacity** - always assume unless there is evidence to the contrary 2. **Maximise capacity** - if lacking capcaity 3. **Bad decisions not necessarily incapable** 4. **Mental disorder or severe communication disorder**

Question 30

What classes of mental disorders can lack capacity?

Answer 30

* **Dementia** * **Delerium** * **Schizophrenia** * **Aphasia** * **Sensory impairment**

Question 31

What are the 5 aspects of decision making that need to be present in order for someone to be deemed to have capacity?

Answer 31

* **Acting** * **Making decision** * **Understanding decisions** * **Communicating decisions** * **Retaining memory of decisions**

Question 32

What is power of attorney?

Answer 32

Power granted by person (when they have the capacity to do so) to make sure that their future decisions are safeguarded, even when they lode the ability to make these decisions themselves

Question 33

What are the different types of power of attorney?

Answer 33

* **Continuing** - financial only * **Welfare** - decisions about health and wellbeing * **Combined** - both financial and decisions

Question 34

What is guardianship?

Answer 34

Legal authority for someone to make decisions and act on behalf of a person who has lost capacity to make certain decisions. May cover money, property, welfare and health

Question 35

What mnemonic could you use to remember causes of delerium?

Answer 35

* **C**onstipation * **H**ypoxia * **I**nfection * **M**etabolic disturbance * **P**ain * **S**leeplessness * **P**rescriptions * **H**ypothermia/pyrexia * **O**rgan dysfunction (hepatic or renal impairment) * **N**utrition * **E**nvironmental changes * **D**rugs (over the counter, illicit, recreational, their partner/neighbour/pets’, alcohol and smoking)