Delirium

Question 1

What is delirium?

Answer 1

Impaired consciousness with intrusive abnormalities of perception and affect

Question 2

Describe the symptoms of delirium

Answer 2

• rapid onset
  impairment of consciousness; clouding, drowsiness, sopor coma
• disturbance of cognition; disorientation for time, place, person, impaired memory and attention, hallucination, illusions, delusions
• psychomotor disturbance; hyperalert / hyperactive or hypoalert / hypoactive or mixed
• disturbance of sleep wake cycle; insomnia, sleep loss, reversal of sleep cycle, nocturnal worsening, disturbing dreams and nightmares
• emotional disturbance

Question 3

Name causes of delirium

Answer 3

• many
• infection
• intracranial / subdural bleed, MI, PE, cardiac failure
• hypoxia
• complications of diabetes, thyroid disorders
• liver failure, pancreatitis
• UTI, renal failure
• alcohol, drugs
• head injury, meningitis, encephalitis, tumours, epilepsy

Question 4

Name risk factors for delirium

Answer 4

• elderly
• cognitive deficit > DEMENTIA
• previous episode
• perioperative; long surgery, emergency surgery
• extremes in sensory experience; hypo / hyperthermia
• existing sensory deficits; deafness / blindness
• immobility
• social isolation
• new environment
• stress

Question 5

What investigations would be conducted for delirium?

Answer 5

• history and full physical examination
• formal cognitive tests (MMSE, 4AT, ACE)
• urine analysis
• FBC, UandEs, LFTs
• thyroid function
• blood glucose
• CRP
• B12 and folate
• CXR
• MRI / CT brain
• consider EEG

Question 6

What is the treatment of delirium?

Answer 6

• identify and treat cause
• manage environment and provide support
• prescribe; antipsychotics are standard treatment, e.g. low dose haloperidol
• review

Question 7

Describe the features of hyperactive delirium

Answer 7

• elderly +/- cognitive impairment
• recent injury e.g. fractures hip
• sudden onset new confusion, agitation, restlessness
• fine during day, overactive in evening, awake overnight with;
• disruptive behaviour
• delusions / hallucinations of persecution

Question 8

Describe the features of hypoactive delirium

Answer 8

• the same demographic as hyperactive
• becomes suddenly quiet, withdrawn, sleepy
• fluctuates throughout the day
• doesnt eat drink, tend to care
• unmotivated, lazy, uncooperative
• not engaging in rehabilitation
• ‘depressed’

Question 9

Describe the features of potassium channel antibody-associated encephalopathy

Answer 9

• middle aged patients
• clinical features; sub acute memory loss, ‘panic attacks’, partial seizures
• investigations; MRI brain, hyperintensity medial temporal structures +/- cortical ribboning
• mild hyponatraemia
• presence VGKC abs diagnostic
• prognosis good if non-neoplastic

Question 10

Describe the features of NMDA receptor antibody encephalitis

Answer 10

• young women; median age 22
• associated teratoma
• prodrome; isolated psych symptoms, global impairment / movement disorders