Delirium

Question 1

Definition

Answer 1

Acute fluctuating change in LOC with inattention, disorganised thinking, cognition, perception

1. Disturbance in attention->inability to sustain or change
2. Change in cognition, or perceptual disturbance
3. Occurred over a short period of time, change from baseline, fluctuating
4. Direct physiological consequence of a GMC/substance and not occurring when only in coma

Question 2

Pathophysiology

Answer 2

Unknown mechanism

1. Neurotransmitter->anticholinergic, +dopamine
2. Inflammation
3. Chronic stress->++cortisol

Question 3

Etiology

Answer 3

1. Cardiovascular: MI, hypoxia
2. Neurological: meningitis/encephalitis, tumor, post-ictal, stroke, Wernickes
3. Kidney: failure, urinary obstruction
4. Liver: hepatic encephalopathy
5. Endocrinology: hypo/hyperglycemia, hypercarbia, alcoholic ketoacidosis, hyponatremia, hypercalcemia, thyrotoxicosis
6. Dehydration
7. Constipation
8. Drug intoxication/withdrawal
9. Sepsis

Question 4

History

Answer 4

1. Medication review
2. Previous cognitive status
3. Co-morbidities
4. Pain
5. Alcohol and drug
6. Environmental

Question 5

Physical examination

Answer 5

1. Vitals
2. Hydration
3. Pupils->drugs, W/D, CVA, +ICP
4. Lung examination: infection, CHD, COPD
5. CV->CAD, MI
6. Abdominal: intra-abdominal infection, constipation
7. Suprapubic tenderness->UTI, obstruction
8. Hip tenderness
9. Neurological
10. Mental status examination

Question 6

Initial investigations

Answer 6

FBC
UEC
LFTs
ABG
Glucose
Urinalysis
CXR
ECG
Drug levels

Question 7

Further investigations

Answer 7

CT/MRI
LP
EEG->generalised slowing

Question 8

Management

Answer 8

1. Identify and treat underlying cause
2. Medication review
3. Non-pharmacological
4. Pharmacological

Question 9

Non-pharmacology approach

Answer 9

1. Continuous observation
2. Monitoring vital signs
3. Keep oriented, quiet, calm environment
4. Hydration, analgesia, nutrition
5. Approach from the front

Question 10

Medication if required

Answer 10

1. Thiamine (before glucose) if suspect alcohol component
2. Haloperidol OR olanzepine OR risperidone
3. If EPSE->bentripine