Delirium

Question 1

What is delirium?

Answer 1

Acute deterioration in mental functioning,
arising over hours or days,
triggered mainly by acute medical illness, surgery, trauma or drugs

Question 2

Risk factors for delirium? (10)

Answer 2

elderly, 
pre-existing cognitive impairment, 
post-op, 
sensory impairment e.g. deaf/blind, 
previous Hx of delirium, 
drug/alcohol dependence, 
depression, 
polypharmacy, 
multiple co-morbidities e.g. Parkinsons, CVD, 
ICU admission

Question 3

Features of delirium?

Answer 3

acute onset, 
fluctuating course, 
altered conscious levels (hyper/hypo), 
inattention/decreased awareness, 
disorganised thinking

Question 4

Assessment of delirium?

Answer 4

4AT or CAM (Confusion Assessment Method),

TIME bundle

Question 5

Basis of management of delirium?

Answer 5

Identify and treat underlying cause

Question 6

What neurotransmitter is particularly deranged in brain in delirium?

Answer 6

ACh

Question 7

Common causes of delirium? (8)

Answer 7

infection, e.g. chest, urinary tract, 
dehydration, 
fever, 
polypharmacy, 
hip fracture,
constipation, 
fluid overload, 
catheterisation

Question 8

DELIRIUM mnemonic causes

Answer 8

Drugs, 
Electrolyte disturbance e.g. hyponatraemia, 
Lack of drugs (alcohol withdrawal),
Infection, 
Reduced sensory input, pain, 
Intracranial e.g. stroke/subdural, 
Urinary retention/constipation, 
Metabolic e.g. AKI, hypoglycaemia, hypothyroid, B12/folate, calcium

Question 9

How does dementia differ to delirium in terms of onset, course, duration, activity, alertness, attention, mood, thinking, perception?

Answer 9

Dementia: slow, progressive, months to years, wandering/agitated, generally alert, normal attention, low mood, word-finding difficulties, usually normal perception,
Delirium: sudden, short & fluctuating, hours to less than month, restless/agitated (hyper) or sleepy/slow (hypo), fluctuating alertness, impaired attention, fluctuating emotions, disorganised thinking, distorted perception

Question 10

Which type of delirium is harder to diagnose and has twice the mortality rate?

Answer 10

Hypoactive delirium harder to diagnose and twice mortality rate

Question 11

Who should be screened for delirium?

Answer 11

All patients >65 years on admission to hospital

Question 12

4AT components?

Answer 12

Alertness,
AMT4 (Orientation) (age, DOB, place, current year),
Attention (months of year from December backwards),
Acute change or fluctuating course

Question 13

4AT scores parameters

Answer 13

4 or > - possible delirium +/- cognitive impairment,
1-3 - possible cognitive impairment,
0 - delirium or severe cognitive impairment unlikely

Question 14

What is the TIME bundle?

Answer 14

Think triggers,
Investigate and intervene,
Manage,
Explain

Question 15

What examination is particularly important for delirium?

Answer 15

Neuro!!

Question 16

What is T in Time bundle?

Answer 16

Think triggers -> SEWS, BG, meds history, alcohol history, urinary retention, constipation, pain review

Question 17

What is I in Time bundle?

Answer 17

Investigation and intervene -> assess hydration, bloods, look for infection signs, ECG i.e. do NEWS score and intervene asap

Question 18

Investigations for delirium?

Answer 18

Bloods (FBC, U&Es, LFTs, CRP, Ca, B12/folate, Mg, TSH, glucose),
culture if septic,
ECG,
Imaging depending on presentation (bladder scan, CT head if focal neurology)

Question 19

A review of what is very important in delirium?

Answer 19

Medication!!

Question 20

First line management for agitation in delirium is non-pharmacological. What is this?

Answer 20

reassurance,
reorientation,
optimisation of sensory input e.g. make sure can hear and see

Question 21

If medication required for agitation in delirium, what is first line after non-pharmacological measures?

Answer 21

haloperidol (less S/E than Benzos)

Question 22

What charts should be kept for delirium patient management?

Answer 22

Food chart,
fluid chart,
bowel chart

Question 23

If medication required for agitation in delirium, what is first line after non-pharmacological measures?

Answer 23

haloperidol 500mcg oral,

if not oral then 500mcg IM

Question 24

What 3 charts should be kept for delirium patient management?

Answer 24

Food chart,
fluid chart,
bowel chart

Question 25

What is haloperidol contraindicated in?

Answer 25

Hx of Parkinsons or Lewy body dementia

Question 26

What is alternative to haloperidol when it is contraindicated?

Answer 26

lorazepam 500mcg-1mg oral

Question 27

What additional factor should be assessed in delirium patients and what form filled out?

Answer 27

Capacity should be assessed and Adults with incapacity (AWI) form

Question 28

Why should diagnosis of delirium be documented in notes and in discharge document?

Answer 28

increased risk further episodes,
increased risk of dementia,
recovery can take months

Question 29

List 6 preventative principles for delirium?

Answer 29

minimal moves in hospital, 
regular orientation, 
glasses & hearing aids, 
pain control, 
nutrition/hydration, 
meds review,

Question 30

How can delirium be prevented in surgical patients? (4)

Answer 30

minimise prolonged anaesthesia,
pain control post-op,
early mobilisation,
early bladder/bowel function review