Delirium Flashcards
Define delirium
A common and serious clinical syndrome characterised by a disturbance of attention which is acute** in onset and is **fluctuating.
There is an additional disturbance of cognition such as memory, orientation or perception.
What is the DSM 5 criteria for delirium?
- A disturbance in attention (reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to environment)
- An acute change that develops over a short period of time (hours - days) and tends to fluctuate
- An additional disturbance in cognition (memory deficit, disorientation, language, perception, visuospatial ability)
- Changes NOT accounted for by another pre-existing, evolving or established neurocognitive disorder
- Evidence from history, physical exam or lab findings of an organic cause (medical condition, substance intoxication or withdrawal, medication side effect)
What are the 2 main subtypes of delirium?
- Hyperactive
- Hypoactive
N.B. Patients can fluctuate between these -‘mixed’
Describe some clinical features of hyperactive delirium
- Increased motor activity
- Agitation
- Hallucinations
- Inappropriate behaviour
- Aggression
- Delusions
What subtype is often the ‘typical’ delirium presentation?
Hyperactive
Describe some clinical features of hypoactive delirium
- Reduced motor activity and lethargy
- Excessive sleeping
- May appear withdrawn
- Loss of appetite
- Not moving as much
- Not talking as much
What can hypoactive delirium sometimes be confused with?
Depression
What is the prevalence of delirium in all elderly inpatients?
20-30%
What is the prevalence of delirium in all patients with dementia??
66%
How can delirium affect patient outcomes in hospital?
◦Longer lengths of stay
◦More hospital associated complications, such as pressure sores and falls
◦More likely to be admitted to long term care
◦More likely to have underlying dementia (diagnosed or undiagnosed)
◦More likely to die
Is delirium reversible?
YES
Give some risk factors for delirium
- Age >65
- Serious illness
- Hip fracture
- Known dementia
What question can be used to initially screen for delirium?
Is this person more confused than normal?
If the patient does appear to be more confused than normal, what are 2 different screening tools that can be used when screening for cognition?
- 4AT
- AMTS
What is involved in the AMTS?
Abbreviated Mental Test Score
This is composed of 10 questions:
- Age
- Time (to the nearest hour)
- Recall (e.g. ask the patient to remember the address and get hem to repeat it back to you later)
- Current year
- Current location
- Recognise 2 people (e.g. relatives, carers, likely profession of doctor/nurse)
- DOB
- Year of 1st / 2nd word war
- Name of current monarch / prime minister
- Count backwards from 20 to 1
What score on the AMTS implies cognitive impairment?
<8
Give some limitations of the AMTS
- Patients with a reduced GCS
- Language barrier
- Younger generation (e.g. WW1 dates)
What is involved in the 4AT?
- Alertness
- AMT4 cognition test → age, DOB, location, current year
- Attention → ask patient to list months in reverse order
- Acute change or fluctuating course
What is the first step in the management of delirium?
Find and Treat Reversible Causes
Reversible causes of delirium → PINCH ME
Pain
Infection
Nutrition
Catheters and constipation
Hypoxia and hydration
Medications and metabolic
Environment
How can ‘pain’ as a cause of delirium be managed?
- Consider causes of pain
- Look for non-verbal signs of pain
- Consider prescribing analgesics e.g. paracetamol
Which infection most commonly causes delirium in the elderly?
UTI
What examination finding may indicate a UTI in a patient with delirium?
Suprapubic tenderness
What investigations should be considered if an infection is thought to be the cause of delirium?
Blood tests - FBC (raised WCC), CRP (raised)
MSU (raised nitrites or leukocyte esterase)
In which patients would a head injury be considered to be the cause of delirium?
Patients on anticoagulation with a history of head injury regardless of neurology OR
If any focal neurology
Which investigation would be done in patients with a suspected head injury presenting with delirium?
CT head
Define carphology
The motion of delirious or senile patients, especially motions of searching for and grasping at imaginary objects, plucking at bedclothes. An aimless semiconscious plucking at bedclothes observed in conditions of exhaustion or stupor or in high fevers.
Which 2 factors alone can cause delirium without any deeper organic cause? (N.B. this should only be considered as a diagnosis of exclusion)
Change of environment + sensory impairment (e.g. vision, hearing)
Poor nutrition can precipitate delirium, but more often is a consequence of the increased confusion. What simple measures can encourage oral intake on the ward?
- Well fitting dentures
- Treating oral thrush
- Appetising meals/finger foods
- Red trays and dementia crockery and cutlery
What is the purpose of a red tray on the wards?
A red tray is used on the wards, in hospital to help staff identify which patients need extra attention when eating, or need foods that have a modified texture (such as mashed or pureed foods).
The aim of using a red tray is to monitor and help these patients when eating so their dietary needs are met.
Which clinical sign may be present if constipation is thought to be the cause of delirium?
- Distension
- Palpation, especially in thin patients, may reveal hard, palpable stool in the colon.
Which investigations could be done constipation is thought to be the cause of delirium?
Abdo exam
PR exam
Management for constipation as the cause of delirium?
Laxatives
Stool chart
Ensure regular toileting regime
Which clinical sign may be present if urinary retention is thought to be the cause of delirium?
Palpable bladder during abdo exam
Which investigations could be done urinary retention is thought to be the cause of delirium?
Bladder scan
Which investigation could be done if hypoxia is thought to be the cause of delirium?
Check oxygen saturations
Dehydration can precipitate or be a consequence of delirium. What investigation can be done to assess dehydration?
urea and electrolytes
Management for dehydration as the cause of delirium?
- Beside hydration assessment
- Offer regular drinks
- Ensure drinks are within reach
- Consider s/c or IV fluids if not drinking adequately
Give some ways in which drugs can lead to delirium
- Opioids
- Withdrawal
- Illicit drugs
- Intoxication
- Hypoglycaemia
Which investigation could be done if drugs are thought to be the cause of delirium?
Review medications and stop unnecessary drugs
Give a list of investigations to do in any patient presenting with delirium
- Bloods - FBC, U&Es, LFTs, TFTs, CRP
- Extra bloods - Calcium, B12, folate, TFTs
- Capillary blood glucose
- CT head scan (if head injury suspected)
- Urinalysis
- Med chart
- O2 sats
- Abdo exam
- Bladder scan
- PR exam
Non-pharmalogical management of delirium should always be first line.
When should medication only be considered?
If the patient is a risk to themselves or others → start low go slow
What is the 1st line pharmacological treatment of delirium?
Low dose haloperidol
If benzos are to be used → lorazepam is 1st line due to rapid onset and short half-life
What class of medication is haloperidol?
antipsychotic
Give some infections that can cause delirium
- UTIs
- Pneumonia
- Cellulitis
- Ulcers
Give some nutritional deficiencies that can cause delirium
B12
Folate
Hypoglcyaemia
What hormone electrolyte imbalances can lead to delirium?
- Calcium - hypercalcaemia
- Sodium - hyponatraemia
- Glucose - hyper/hypoglycaemia
- Thyroid - hypothyroidism
What kidney issues can lead to delirium?
AKI
CKD
What brain pathologies can lead to delirium?
REMEMBER TO ASK ABOUT FALLS
- Stroke
- Subdural
- Tumour
Which conditions can lead to hypoxia or hypercapnia that can then lead to delirium?
- Infection
- Heart failure
- Lung disease e.g. COPD
Which drugs are known to precipitate delirium (so should be avoided in these patients)?
Opiates, benzos
