Delirium

Question 1

What is this a presentation of?

Globally impaired cognition, perception and consciousness developing over hours/days with a fluctuating course.

Answer 1

Delirium

Question 2

What is the epidemiology of delirium?

Answer 2

Affects 50% of inpatients over 65 years old.

Question 3

What are the clinical features of delirium?

Answer 3

1. Marked memory deficit
2. Disordered/disoriented thinking
3. Reduced attention span and focus
4. Reversal of sleep/wake cycle
5. Tactile/visual hallucinations

Question 4

What is the difference between hyperactive and hypoactive delirium?

Answer 4

1. Hyperactive - restlessness, mood lability, agitation, aggression, wandering, pulling out catheter, into others beds.
2. Hypoactive - most common, slow and withdrawn.
3. Can be mixed

Question 5

What are the risk factors for developing delirium?

Answer 5

Over 65 years old, dementia/previous cognitive impairment, hip fracture, acute illness, pain, polypharmacy.

Question 6

What are the reversible causes of delirium?

Answer 6

P - Pain (can be post-traumatic)
I - Infection
N - Nutrition
C - Constipation
H - Hydration
M - Medications (new/withdrawal)
E - Environment

Question 7

How is delirium investigated?

Answer 7

1. Look for cause
2. FBC, U&Es, LFTs, glucose, TFTs, CRP
3. Blood gas
4. Septic screen - urine dip, blood culture, CXR
5. Alcohol and drug screen
6. 4AT screen
7. Consider - ECG, malaria films, LP, EEG, CT

Question 8

What is the general management for delirium?

Answer 8

1. Reorientate patient frequently
2. Low stimulus and well lit side room
3. Hearing aids/glasses
4. Visible clocks and calendars
5. Visits from friends and family
6. Monitor fluid balance, encourage oral intake
7. Restrict daytime napping, minimise night-time disturbance
8. Avoid/remove catheters
9. Discontinue unnecessary medication

Question 9

What is the management for acute agitation in delirium?

Answer 9

1. If dementia with Lewy body, PD, cardiac disease - oral lorazepam 0.5-1mg
2. If not - haloperidol 0.5-2mg IM/lorazepam 0.5-1mg/olanzapine

Question 10

What are the areas of the abbreviated mental test (AMT) and what is considered an abnormal score?

Answer 10

1. Age, time, address for recall, year, name hospital, recognition of two people, date of birth, year of famous event, name of monarch, count backwards from 20 to 1, recall address.
2. Each scores 1 point (10 max), 7 or less is abnormal