Delirium

Question 1

What are the key features of delirium?

Answer 1

• Acute onset, fluctuating course
  
  • Usually develops over hours to days, worse at night
• Inattention
• Disorganised thinking (e.g. rambling/irrelevant conversation)
• Altered level of consciousness

Question 2

Describe the main types of delirium

Answer 2

• Hyperactive
  
  • Hyperarousal, increased sensitivity to surroundings
  • Verbal/physical aggression
  • Restlessness, wandering
  • Psychosis
• Hypoactive
  
  • Lethargy, sluggishness, confusion, low mood
• Mixed

Question 3

What are the main features distinguishing delirium from dementia?

Answer 3

• Memory, attention, thinking, insight more affected in delirium. Delirium more acute. Night effect more pronounced

Question 4

What are some risk factors for development of delirium?

Answer 4

• Age
• Pre-existing dementia
• Recent surgery
• Bone fractures
• CNS structural abnormalities
• Infections (especially chest and urinary)
• Hypoalbuminaemia
• Sodium change
• Severe illness
• Medications
• Polypharmacy
• Dehydration
• Depression
• Visual/hearing impairment
• Substance abuse

Question 5

What are the broad causes of delirium?

Answer 5

• Secondary to general medical condition
• Secondary to substance intoxication
• Secondary to substance withdrawal
• Secondary to multiple aetiologies

Question 6

What are the important aetiologies of delirium?

Answer 6

• IWATCHDEATH
• Infection, withdrawal, acute metabolic, trauma, CNS pathology, hypoxia, deficiencies, endocrinopathies, acute vascular, toxins, heavy metals

Question 7

What are the baseline tests you would review or order in a delirium screen?

Answer 7

• FBE, UEC, BGL, LFTs, ESR/CRP, MSU, CXR, ECG, SpO2
• FBE - infection/anaemia
• UEC - electrolyte derangement
• BGL - hypo/hyper
• LFT - failure
• ESR/CRP - inflammation
• MSU - UTI

Question 8

What are the broad management principles for a patient with delirium?

Answer 8

• Monitor vitals and fluid input/output
• Good oxygenation
• Cease non-essential medications, minimise opioids, benzos. Try not to catheterise if at all avoidable
• Non-pharmacological strategies
• Pharmacological strategies
  
  • Antipsychotics
    
    • Haloperidol
• Atypical antipsychotics e.g. risperidone, olanzapine (especially if EPSs are an issue)
• Benzodiazepines (in EtOH withdrawal)

Question 9

Describe some non-pharmacological strategies for the management of delirium

Answer 9

• Reorientation, calendars, clocks, close nursing supervision, windows, family, hearing aids, glasses, avoid restraints, correction of dehydration (subcut fluids)