Acute confusional state (Delirium)

Question 1

What is it?

Answer 1

Clinical syndrome of transient + fluctuating global cognitive impairment a/w behavioural abnormalities

Question 2

Common types of delirium? (3)

Answer 2

Agitated delirium
Hypoactive delirium
Mixed delirium

Question 3

Risk factors?

Answer 3

Elderly or very young
Pre-exsiting dementia
Blind or deaf
Post-operative 
Alchohol (Delirium Tremens) 
Benzodiazepine treatment

Question 4

Why type of patients is it common in?

Answer 4

Medical and surgical inpatients (10-20%)

Question 5

What is the most common aetiology?

Answer 5

Drugs - alcohol, BZD’s, anticholinergics, pscyhotrophics, lithium, diuretics, digoxins, steroids, NSAIDs

Question 6

Other aetiological causes? (4) IT ME VIP

Answer 6

Infective: UTI, L/URTI, abscess, cellulitis
Metabolic: anaemia, electrolyte disturbance, hepatic encephalopathy heart failure
Intracranial - CVA, head injury
Endocrine: DM, hypoglycaemia, pituitary, thyroid, parathyroid or adrenal disease, vitamin deficiency (B12, folate, nicotinic acid)

Question 7

Clinical features? (12)

Answer 7

Fluctuating consciousness and symptoms
Poor concentration
Memory deficits
Sleep disturbance, drowsiness
Hallucinations or illusions
Sun down syndrome – illusions and delirium when sun sets
Agitation 
Emotional lability
Neurological signs
Psychotic ideas
Withdrawn and quiet

Question 8

Investigations? (9)

Answer 8

Mini mental state exam
Full exam, including looking for sources of infection
FBC, Creatinine – important to assess renal function, U&Es, glucose, calcium, magnesium, cultures
O2 sats – hypoxia can cause
LFTs, TFTs
Urine dip and output
Syphilis test
ECG

Question 9

Non-biological Mx? (5)

Answer 9

Rx underlying cause
Encourage fluid + nutrition 
Correct electrolyte disturbances
Ensure sensory aids are in place - hearing aids + spectacles
Encourage mobilisation

Question 10

Biological Mx? (3)

Answer 10

Haloperidol 0.5 mg – max 4mg/day
Lorazepam 0.5-1mg – max 4mg/day
Risperidone 1-4mg – max 6mg/day