Delirium Flashcards
what is it?
- Acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma or drugs
- medical emergency associated with increased levels of morbidity and mortality
- can last days and months
- increased risk of complications
pathophysiology
not well understood
• Variable derangement of multiple neurotransmitters (particularly ACh)
• Direct toxic insults to the brain clearly contribute e.g. drugs, hypoxia, low sodium, low glucose
• Aberrant stress responses probably also contribute – cortisol, prostaglandins, cytokine release, serum cholinesterase activity
who gets it?
very common, elderly pre-existing cognitive impairment post-operative depression polypharmacy intensive care admission previous history of delirium
causes of delirium
drugs electrolyte disturbance e.g. hyponatraemia drug withdrawal infection reduced sensory input, pain intracranial e.g. stroke/subdural urinary retention/constipation metabolic e.g. aki, hypoglycaemia, hypothyroid, B12/folate, calcium
how does it present time period?
- Sudden onset, hours, days
- Short, fluctuating course (usually reversible)
- Lasts hours to less than a month
how does hyperactive delirium present?
agitation, restlessness
how does hypoactive delirium present?
sleepy, slow (easily missed)
what are the symptoms of delirium?
- alertness - fluctuates hypervigilant to lethargic
- impaired attention - difficult to converse
- fluctuating emotions
- disorganised, distorted fragmented thinking
- distorted perception - illusions and hallucinations (normally variable) and delusions
how is it screened for?
all patient >65 should be screened for delirium on admission to hospital - provides baseline if no delirium 4 AT score o Alertness o AMT4 o Attention o Acute change or fluctuating course
how is it investigated?
Basically find the cause
…
• Neuro exam – very important
• History
• Full exam – look for any injury
• Pain?
• Don’t forget glucose – elderly patients are at risk of hypoglycaemia
• Medication review - Polypharmacy is an independent risk factor for delirium
• Bloods – FBC, U&Es, LFTs, calcium, B12/folate, Mg, TSH, glucose
• Blood cultures if septic
• ECG
• Imaging – bladder scan, CT head if focal neurology/head injury
how is it managed?
TIME bundle
Think, exclude and treat possible triggers
Investigate and intervene to treat underlying cause
Management plan
Engage and explore
assess capacity
supportive measures - environment, staffing, orientation, sleep, family/carers
non-pharmacological (1st line) management
o Allow patients to safely mobilise
o Sensory input important – glasses and hearing aids working
o Food chart
o Food chart and fluid chart – dehydration exacerbates
o Bowel chart – constipation is common and can be avoided
pharmacological management
reserved for patients where non-pharmacological methods have failed, symptoms threaten safety of patient or to others or significantly distressing psychotic symptoms
o 1st line – haloperidol 500 micrograms orally
- if unable to take oral medication then 500 micrograms IM (DO NOT USE IN HISTORY OF PARKINSONS OR LEWY BODY DEMENTIA)
o In these patients lorazepam 500micrograms -1mg oral can be given
o In patients requiring ongoing anti-psychotic use then early referral to POA is very important
how should delirium be followed up?
o Regularly review patients
o As patients improve – anti-psychotic medication should be reviewed and reduced
o Talk to patients about experiences and offer reassurance – often patients can be embarrassed or worried about delirium
o Delirium diagnosis needs to be documented in discharge paper
o Educate patients family to recognise it
