Delerium

Question 1

Define delerium

Answer 1

The rapid onset (over hours or days) with fluctuating symptoms of

1. Altered level of consciousness with inattention, and
2. A change in cognition (memory deficit, disorientation, language disturbance), or development of perceptual disturbance (hallucination)

Question 2

What is hyperactive delirium?

Answer 2

Agitation and hypervigilance e.g. Irene

Question 3

What is hypoactive delirium?

Answer 3

Quiet and withdrawn, hypoalert (worse prognosis, because it is missed more often)

Question 4

What are the main differences between delirium and dementia?

Answer 4

Differences between dementia and delirium

1. Onset of dementia is gradual, over months to years rather than hours to days in delirium
2. Dementia has a progressive course, rather than a fluctuating in delirium
3. Altered level of attention and consciousness in delirium

Question 5

List the predisposing factors of delirium.

Answer 5

These factors are MULTIPLICATIVE
• Advanced age - have mild/moderate risk of delirium due to associations with below
• Impaired cognition (delirium, previous ABI, disability)
• Previous Hx of delirium
• Depression
• Functional disability or functional dependence (lack of dependence) including immobility
• Dehydration
• Psychoactive drugs
• Visual and hearing impairment
• Chronic co-morbidity
- Dementia - delirium is closely linked to dementia, each is a RF for the other and they often co-exist * the biggest risk factor

Question 6

List the precipitating factors of delirium.

Answer 6

• Drugs
• Primary neurological diseases
• Inter-current illness
• Surgery
• Unfavourable environmental factors - in dwelling catheters
• Sleep deprivation
• Malnourishment
5-10% of elderly patients will develop delirium as an in patient especially at aged care facilities, palliative care, orthogeriatrics, ICU

Question 7

What are the causes of delirium?

Answer 7

• Physical: infection (UTI, respiratory, cellulitis), pain, constipation
• Metabolic: hypoxia, hypo/hyperglycaemia, electrolyte disturbance
- Drug related: alcohol or drug withdrawal, anticholinergics, antidepressants, analgesic, antipsychotics (benzos)

Question 8

Pathogenesis of delirium

Answer 8

Unknown pathogenesis, but reduced cerebral oxidative metabolism causing altered neurotransmitter levels in prefrontal and subcortical areas

Question 9

DDx of delirium

Answer 9

• Depression
• Anxiety
• Psychosis
- Dementia

Question 10

Ix if suspecting delirium

Answer 10

If the person NQR (not quite right), it is delirium until proven otherwise.

1. Bedside: Review drug chart thoroughly for drug related delirium for anticholinergics, antidepressants, analgesic, antipsychotics (benzos) withdrawals particularly from benzos and alcohol
2. Bloods: CRP, WCC, electrolytes (hypo/hypernatraemia), glucose, oxygen
3. Path: urine dipstick, swab and culture obvious sites - in dwelling catheter, cannula site
4. Imaging: CXR, CT brain if Hx of fall with headstrike, anticoagulated, active malignancy, photophobia or neck stiffness
5. Other: ECG

DO MMSE and CAM (confusion assessment score).

Question 11

Diagnosis criteria of delirium

Answer 11

Diagnosis requires 1, 2 and either 3 or 4:

1. Acute onset and fluctuating course
2. Inattention
3. Disorganised thinking
4. Altered level of consciousness

Question 12

Prevention of delirium

Answer 12

• Use glasses or hearing aids to reduce sensory impairment
• Offered adequate food and fluids
• O2 supplementation if indicated
- Minimise sleep disturbance (avoid nursing procedures, reduce noise during sleep hours)

Question 13

Non pharmacological Mx of delirium

Answer 13

• Mainstay treatment is nurse and carer based, only use drugs after non -drug measures have failed
• Treat underlying condition (see Causes)
○ Medications with CNS effects may precipitate and/or aggravate delirium, where possible withdraw slowly, over a few days
• Supportive care
○ Mobilise as much as possible
○ Maintain nutrition and fluid levels
○ Access to day light, then low stimulus at night
○ Family member visits
○ Education for the family
○ Repeatedly reorientating: explain where they are, who they are and what your role is
○ Put in hearing aids, glasses, removing wax
Do not physically restrain is it may aggravate agitation leading to falls and injuries

Question 14

When do you use drug Mx for delirium?

Answer 14

Only consider drug treatment of anti-psychotics if
• Impacting on their own treatment
• Threatens others or self
• Anxiety, delusions or hallucinations cause significant distress to themselves
• Anti-psychotics: best evidence for haloperidol - readily available, easy to titrate (olanzepine has anti-cholingergic effect, so therefore do not use)
Short term only, low dose - extra pyramidal side effects

Melatonin can be used to normalise the sleep wake cycle

Question 15

What is first line for withdrawal related delirium?

Answer 15

Benzodiazepines.

NB only secondary in Mx of non-withdrawal delirium as it can aggravate the patient

Question 16

Complications of delirium

Answer 16

• 12 mth mortality is 35-40%
• Persistent delirium: Median duration of delirium is app 1 week, but often when discharged they still have features of delirium
Advise families: patients can get better, but they will not necessarily get 100% better
• Hypoactive: pressure sores, DVT, pneumonia
• Hyperactive: falls
• Increase length of hospital stay
• Nutrition declines - inability to open packaging and eat
Depression and PTSD