Delirium

Question 1

What is delirium?

Answer 1

Also known as ‘acute confusional state’

Acute (hr-d onset), fluctuating syndrome of disturbed:

• Consciousness
• Attention
• Cognition
• Perception

Question 2

Outline the DSM-5 criteria for delirium

Answer 2

All of:

• Disturbance in attention and awareness from baseline
• Acute onset (typically hours-days); fluctuating severity
• Additional cognitive disturbance
  
  • ^eg. memory deficit; disorientation; language; perception
• Not better explained by another neurocognitive disorder
• Evidence of precipitating event responsible for disturbance

Question 3

Describe the illness course of delirium

Answer 3

• Sudden onset
• Fluctuating course
• Gradual resolution: up to 6-months
  
  • Following effective treatment of underlying cause

Question 4

List the three clinical presentations of delirium

Answer 4

• Hyperactive delirium
• Hypoactive delirium
• Mixed delirium

Question 5

Describe hyperactive delirium

Answer 5

• Psychomotor agitation
• Increased arousal
• Inappropriate behaviour
• Hallucinations: commonly visual
• Delusions: commonly persecutory
• Restlessness and wandering are common

Question 6

Describe hypoactive delirium

Answer 6

• Psychomotor retardation
  
  • Appear quiet or withdrawn
• Lethargy
• Reduced appetite
• Excess somnolence (drowsiness)

Question 7

Describe mixed delirium

Answer 7

Combination of hyperactive and hypoactive delirium with varying presentation over time

Question 8

Name three predisposing factors for delirium

Answer 8

• Elderly or very young
• Pre-existing dementia
• Sensory impairment: ^eg. visual or hearing
• Post-op (especially cardiac)
• Alcohol abuse; benzodiazepine-dependent; poor nutrition
• Serious and/or multiple illnesses; polypharmacy
• Lack of stimulation

Question 9

Provide five precipitating factors for delirium

Answer 9

Delrium is usually multifactorial

• UTI; chest infections; infected pressure sore; sepsis
• Hyperglycaemia; hypoglycaemia; electrolyte abnormalities
• MI; heart failure; stroke; intracranial bleed
• Thyroid dysfunction; PE; COPD exacervation
• Urinary retention; constipation; malnutrition
• Severe uncontrolled pain; major surgery
• Medication changes; alcohol intoxication or withdrawal
  
  • ^eg. opiods; benzodiazepines; steroids
• Hospital admission; emotional stress; sleep deprivation

Question 10

Name five complications of delirium

Answer 10

• High mortality (20% during admission, up to 50% at 1yr)
• Increased duration of stay
• Nosocomial infections
• Institutionalisation and/or re-admission
• Increased risk of:
  
  • Dementia
  • Falls
  • Pressure sores
  • Continence problems
  • Functional impairment; distress for self/carers

Question 11

What is the association between delirium and dementia?

Answer 11

Delirium causes neuronal death ➔ Independent cause (3x more likely) for dementia development and progression

Pre-existing dementia is a predisposing factor for delirium

Question 12

Request three investigations for suspected delirium

Answer 12

• Cognitive testing: 4AT; MoCA; Addenbrooke’s
• Urinalysis
• Sputum culture; CXR
• FBC; CRP
• U+Es; calcium
• HbA1c
• TFTs
• Haematinics: ^eg. B₁₂; folate
• EEG

Question 13

What are the management principles for delirium

Answer 13

• Identify and treat underlying causes
• Environmental and supportive measures
• Avoid sedation unless severely agitated or a risk
• Regular clinical review and follow-up

Question 14

Name four environmental and supportive measures in the management of delirium

Answer 14

• Maintain hydration and nutrition
• Physical environment
  
  • ^eg. Safe environment; good lighting; noise reduction; clocks and calendars; hearing and visual aids
• Human environment
  
  • ^eg. Same staff; firm clear communication; routine; prevent transfer
• Control of distressing physical symptoms
• Avoid unnecessary procedures
• Promote healthy sleep patterns

Question 15

Name three physical environmental factors for optimal management of delirium

Answer 15

• Safe environment
• Adequate lighting
• Noise reduction
• Clocks and calendars
• If appropriate, hearing and visual aids

Question 16

Name two human environmental factors for optimal management of delirium

Answer 16

• Same group of staff
• Firm clear communication
• Routine
• Prevent transfer
• Education for those interacting with patient

Question 17

Outline the managment of a person with delirium who is distressed or considered a risk to themselves or others?

Answer 17

• Verbal and non-verbal de-escalation
• Short-term haloperidol
  
  • Lowest clinically appropriate dose; titrate to symptoms
  • Use with caution or none if Parkinson’s or Lewy body

Question 18

Differentiate dementia from delirium

Answer 18

Delirium has altered consciousness and attention

Dementia:

• Gradual onset (months to years); progressive deterioration
• Normal consciousness; perceptional disturbances occur later
• Normal sleep-wake cycle

Delirium:

• Acute onset (hours to weeks); fluctuating course
• Impaired consciousness; perceptional disturbances common
• Disrupted sleep-wake cycle.