Confusion and delirium

Question 1

What is delirium?

Answer 1

An acute or sub-acute confusional state usually with an organic cause

Question 2

Who is delirium particularly common in? What % of this group of inpatients will have delirium at any one time?

Answer 2

The elderly.

Up to 20% of elderly inpatients will have delirium at any one time

Question 3

What are some causes of delirium?

Answer 3

INFECTION - common (look for UTI, chest infection or cellulitis infection)
Hypoxia
Vascular (stroke, TIA)
MI
Retention of urine
Constipation
Intracranial inflammation (meningitis and encephalitis)
Metabolic (uraemia, hypoglycaemia, hypo/hypernatraemia, low Hb, low nutrition)
Head injury (raised ICP, SOL)
Epilepsy
Nutritional (thiamine, nicotinic and vit B12 all cause acute delirium)

PINCH ME (Pain, INfection, Constipation, deHydration, Medication, Environment)

Question 4

What are the main signs and symptoms of delirium?

Answer 4

Mnemonic - DELIRIUM
Disordered thinking - slow, irrational or jumbled
Extreme emotion - euphoric, fearful, angry
Language impaired - dysphasic
Illusions/delusions or hallucinations
Reversal of the sleep/wake cycle - nocturnal
Inattention - unable to focus on one thing
Unaware - do not know what time/day it is
Memory deficits

Question 5

What tests/investigations should be done in the delirious patient?

Answer 5

FBC (infection), U&E (electrolytes), CRP, LFT, Glucose, ABG
ECG
CT head
MRI

Question 6

How should delirium be managed in the ED?

Answer 6

Identify and treat underlying cause e.g. infection/retention etc.
Keep calm and orientated (quiet side room with low light and clocks)
Can consider sedative medication if agitated and not able to be calmed (midazolam)