Delirium

Question 1

What is the presentation/ definition of delirium + specificers of type and style

Answer 1

Acute onset of disturbance in level of awareness/ ability to direct, focus and sustain attention (hours to days)

Presents with impaired
Cognitive function - confusion, reduced
concentration, slow response

Perception esp. visual hallucinations, delusions, illusions

Physical function
- sleep disturbance (daytime somnolence, nighttime agitation, changes in appetite
- impaired mobility, reduced movement, agitation, restlessness,

• Social behaviour - uncooperative, withdrawal/ alterations in communication/mood [anxiety fear etc]

Specify time :
- Acute - lasting hours to days
- Persistent - lasting weeks to months

STYLE
- Hyperactive - hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation and/or refusal to cooperate with
medical care

• Hypoactive - hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor
• Mixed - normal levels of psychomotor activity even though attention and awareness are disturbed. Activity level may fluctuate rapidly

Question 2

What are the potential causes of delirium and history questions

Answer 2

• Drugs ? any new meds started or stopped? e.g. sedatives, anticholinergics
• ears/ eyes : impaired sensory input, unfamiliar surroundings
• Low oxygen state (MI, stroke, anaemia etc.)
• Infection ? PUS any fever or pain
• Retention of urine/stool ?problems passing urine/stool, pain/ bleeding ?
• Ictal ; CNS pathology ; poor sleep
• Under-hydration, undernutrition ? eating drinking - liver renal failure
• Metabolic - hypoglycaemia, hyponatremia, calcaemia
• Sleep deprivation, subdural haematoma

Question 3

What is the DSM 5 criteria for delirium

Answer 3

A. Disturbance in attention (i.e. reduced ability to direct/focus/shift attention) and awareness (reduced orientation to the environment)

B. Disturbance develops over a short period of time (usually hours to days), represents a change from baseline attention/awareness and tends to fluctuate in severity during the course of the day

C. Additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception)

D. Criteria A and C are not better explained by another preexisting/established/ evolving neurocognitive disorder and do not occur in the context of severely reduced level of arouse (e.g. coma)

E. Evidence from history/examination/
laboratory findings that the disturbance is a direct physiological consequence of
another medical condition, substance
intoxication or withdrawal (drug of abuse, medication), or exposure to a toxin, or is due to multiple aetiologies

Question 4

Differentials for delirium

Answer 4

• Substance intoxication delirium
• Substance withdrawal delirium
• Medication-induced delirium
• Delirium due to another medical condition
• Delirium due to multiple aetiologies

Major neurocognitive disorder (dementia)
- Mild neurocognitive disorders
Neurocognitive disorder not otherwise specified

Question 5

what are the investigations for delirium

Answer 5

Obs including O2 sats, ABG
- FBC , U&E, LFTS, TFT, glucose, ESR/CRP, B12
- Blood cultures
- MSU
-CXR
- ECG
- LP , neuroimaging , EEG

Collateral history and observation for changes in behaviour

CAM - confusion assessment method

Question 6

Things to note in MSE for delirium

Answer 6

CAM
2 of the first features
Acute onset/flucuating course
- “Has the patient’s mental status changed abruptly from baseline?”

“Did the abnormal behavior fluctuate during the day (ie, tend to come and go or increase and decrease in severity)?

Inattention
“Did the patient have difficulty focusing attention (eg, was easily distracted or had difficulty following what was being said)?”

+ one of the following
Disorganised thinking :”Was the patient’s thinking disorganized or incoherent (eg, evidenced by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?”

Altered level of consciousness
- vigilant, drowsy but easily aroused (lethargic), difficult to arouse (stupor), unarousable (coma)

Question 7

What is the safety considerations for management of delirium

Answer 7

o Safety – 1:1 nursing or close
monitoring - Ensure obs are stable,
adequate hydration, nutrition, personal
hygiene, bowel and bladder function.
- Falls prevention
- Ensure hearing aids / glasses present
Quiet and well-lit environment
- Frequent reorientation
- Early mobilisation

Note patients will have impaired decision making capacity for refusing treatment, - should proceed in best interest

Question 8

Biological treatment of delirium

Answer 8

1. investigation and treatment of cause
2. Withhold non-essential medication esop anticholinergics or benzos.
3. do not suddenly withdraw any chronically used psychotropic drug without good reason
4. verbally de-escalate, try to resist oversedating, only use one sedating drug

DRUGS
1. Haloperidol 0.5-1mg BD orally with additional doses Q4H prn
SE: EPSE, prolonged QT

2. Quetiapine 25mg for parkinsons
   Risperidone 500mcg BD
   olanzepine 2.5 mg

3.Benzodiazepine (e.g. lorazepam 0.5-1.0mg orally or IM with additional doses every 4hrs PRN)
Indications - Parkinson’s disease, alcohol withdrawal, NMS. (associated with worsening)
- Side Effects - paradoxical excitation,
respiratory depression, oversedation

Refer to psychiatry or MHSOA

Question 9

Explanation of delirium to lay person

Answer 9

• You were admitted to hospital because of a sudden change in your concentration/perceptions/behaviour/sleep patterns.
• This state of confusion is called delirium and it can be triggered by a number of different causes including infections, dehydration, constipation, alcohol or medications, low oxygen getting to the brain or heart, impaired sight/ hearing in an unfamiliar environment.
• Delirium is quite common in older people and those with many or severe health problems as they tend to be more sensitive to changes in their health.
• Once the underlying cause has been found and treated, people are expected to recover from this state. Practical things that can be done to help someone with delirium is making sure they have reminders of the time of day, having their hearing aids and glasses, eating, using the toilet and sleeping at regular times and managing their pain.