Confusion and delirium

Question 1

What is delirium?

Answer 1

Delirium comes over over the time course of hours to a few weeks and there is fluctuation in symptoms.
They are distractible and disorganised in thinking, slow to respond and go off on tangents. They may have hallucinations and sleep patterns become disrupted with sleeping in the day and awake at night.
They have short-term memory loss (due to inattention) and emotionally labile.

Question 2

What differential diagnoses should you consider apart from delirium?

Answer 2

Schizophrenia/psychosis
Dementia
Aphasia

Question 3

What are the groupings of causes of delirium?

Answer 3

Systemic
Intrinsic
Vascular
Extrinsic

Question 4

What are systemic causes of delirium?

Answer 4

Metabolic

• hyper- or hypo-natraemia
• Hypercalcaemia
• Hypoglycaemia
• Hepatic failure
• Hypothyroidism

Toxic

• dugs, esp. antiparkinsonian medications and illicit drugs
• alcohol or alcohol withdrawal

Infection

• septicaemia
• UTI
• pneumonia

Question 5

What are the intrinsic causes of delirium?

Answer 5

Infectious - meningitis, encephalitis, malaria
Paroxysmal - epilepsy, ictal or post-ictal
Immunological - lupus, limbic encephalitis

Question 6

What are the vascular causes of delirium?

Answer 6

Post-stroke

SAH

Question 7

What are the extrinsic causes of delirium?

Answer 7

Subdural haematoma
Post-traumatic
Hydrocephalus

Question 8

What investigations should be performed in a patient with delirium?

Answer 8

Metabolic screen - glucose, sodium, urea, calcium, LFTs, GGT, drug screen, blood gases, red cell transketolase.

Infection screen - FBC and viscosity, blood cultures, urine microscopy and culture, CXR.

Neurological investigations - brain scan (CT or MRI), lumbar puncture if CT is normal, EEG.

Question 9

What important knowledge should be collected from a relative/friend of the patient with delirium?

Answer 9

• Prior level of mental function
• Timing of the onset of the confusion
• Coexisting medical problems
• Drug usage
• Alcohol intake and diet
• Any history of trauma
• Any history of recent collapse
• History of foreign travel

Question 10

What is the management of all individuals with delirium?

Answer 10

1. Monitor and maintain homeostasis - hydration, electrolytes, glucose, oxygen.
2. Keep patients in a standardised environment, with people known to them looking after them - keeps them less agitated.
3. Providing cues to help orientate them about date and place.
4. Sedatives such as haloperidol and chlopromazine are often useful

Question 11

What is given to those patients suffering delirium from alcohol withdrawal?

Answer 11

Benzodiazepines such as chlordiazepoxide and lorazepam.