Delirium

Question 1

Delirium is characterised by:

Answer 1

Acute onset (hour to days)
Fluctuating symptoms (alters throughout the day)
Disturbance in awareness and attention (reduced awareness, distractible)
Disturbance in cognition (e.g. memory, language, disorientation)
Evidence of an organic cause (e.g. medical condition, medication, intoxication)

Question 2

An estimated …% of older adults (> 65 years) admitted to hospital will develop delirium during the course of their stay. In addition, delirium may complicate up to 87% of intensive care admissions.

Answer 2

An estimated 50% of older adults (> 65 years) admitted to hospital will develop delirium during the course of their stay. In addition, delirium may complicate up to 87% of intensive care admissions.

Question 3

Delirium may be classified into hyperactive, hypoactive or mixed.

The clinical features of delirium allow it to be divided into three subtypes:

Answer 3

Hyperactive delirium: characterised by inappropriate behaviour, agitation or hallucinations. Wandering and restlessness are common
Hypoactive delirium: characterised by reduced activity. Patients may appear quiet, lethargic, withdrawn and have reduced concentration
Mixed delirium: characterised by the presence of both hypoactive and hyperactive features

Question 4

Many conditions can precipitate the development of delirium and assessment involves a wide look into all the possible precipitating factors. It is important not to forget simple problems such as a change in environment, hearing impairment, emotional stress and constipation.

We can think about precipitating factors based on systems:

Answer 4

Neurological: brain injury, subdural haematoma, stroke, cerebrovascular disease
Cardiovascular: heart failure, myocardial infarction, atrial fibrillation
Respiratory: aspiration, pneumonia, exacerbation of chronic obstructive pulmonary disease
Gastrointestinal: constipation, malnutrition, bleeding
Urological: urinary retention, urinary tract infections
Skin & joints: cellulitis, pressure sores
Metabolic / endocrine: thyroid disease, hypo-/hyperglycaemia, hypo-/hypernatraemia
Medications: anti-histamines, tricyclic antidepressants, anti-cholinergics
Other: alcohol, uncontrolled pain, sleep deprivation, change in environment, hearing impairment.

Question 5

Older age is one of the major risk factors for developing delirium.

Several factors predispose to the development of delirium:

Answer 5

Age (> 65 years)
Multiple co-morbidities
Frailty
Malnutrition
Sensory impairment (vision, hearing)
Functional impairment
Alcohol excess
Major injury (e.g. hip fracture)
Cognitive impairment (e.g. dementia)

Question 6

Abnormal consciousness - delirium

Answer 6

Reduced level of awareness and focus
Drowsy or semicomatose
Hyperactive

Question 7

Abnormal cognition - delirium

Answer 7

Memory loss
Disorientation (e.g. to place, person or time)
Poor language (e.g. loss ability to speak a second language)
Poor speech

Question 8

Abnormal thinking - Delirium

Answer 8

Distractible and inattention (e.g. unable to follow commands)
Disorganised thinking (e.g. poor flow of ideas, disorganised speech, unable to express their needs)

Question 9

Abnormal perception in delirium

Answer 9

Abnormal perception

Visual or auditory hallucinations
Paranoid delusions
Misperception

Question 10

DSM-5 criteria - delirium

This is divided into five domains that we have simplified:

Answer 10

Disturbance in awareness (e.g. disorientated to time, place, person) and attention (e.g. unable to subtract serial 7’s)
Acute onset (hours to days), acute change from baseline, and fluctuant
Disturbance in cognition (e.g. memory loss, misperception)
Not better explained by a pre-existing, established, or evolving neurocognitive disorder and absence of severely reduced GCS
Evidence of an organic cause (i.e. medical condition, medication, intoxication)

Question 11

A number of cognitive assessment tools can be used at the bedside to enable a diagnosis of delirium. Three commonly used criteria include:

Answer 11

Confusion Assessment Method (CAM)
The 4A’s test (4AT)
Abbreviated mental test (AMT)

Question 12

Confusion Assessment Method (CAM)

Answer 12

Overview: brief assessment tool based on four features
(1) Acute & fluctuating course
(2) Inattention
(3) Disorganised thinking
(4) Altered level of consciousness
Time: < 5 minutes
Setting: hospital or community
Diagnosis for delirium: presence of 1 AND 2 plus either 3 OR 4

Question 13

The 4A’s test (4AT)

Overview: a screening tool for delirium that involves four screening questions

Answer 13

(1) Alertness
(2) Four AMT questions: age, date of birth, place, current year
(3) Attention: list months in reverse order starting with December
(4) Acute change or fluctuating course
Time: < 5 minutes
Setting: hospital
Score: 1-3 (possible dementia), 4-12 (possible dementia/delirium)

Question 14

Abbreviated mental test (AMT)

Answer 14

Overview: a ten item scoring tool predominantly used in hospital settings (e.g. hospital ward).
Time: < 5 minutes
Setting: hospital and General practice
Cut-off for delirium: 6-7/10

Question 15

Bedside - delirium

Answer 15

Observations
ECG
Cultures: sputum, urine, stool
Capillary blood glucose

Question 16

Bloods - delirium

Answer 16

Full blood count
Urea & electrolytes
Liver function tests
Bone profile
Calcium
HbA1c
Haematinics: vitamin B12, folate
Thyroid function tests
C-reactive protein
Drug levels
Syphilis serology: classically part of the confusion screen

Question 17

Managing delirious patients - overview

Answer 17

Managing patients with delirium can be very difficult. It is important to involve relatives and carers whenever possible who can make a huge difference with management of behavioural abnormalities.

Management involves addressing the underlying precipitating cause(s) and ensuring the patient is safe. Part of this process involves completely a mental capacity assessment in line with the Mental Capacity Act and imposing the least restrictive measures necessary to ensure safety.

Question 18

Simple deescalation methods can include:

Answer 18

Address underlying cause of behaviour (e.g. thirst, need for toilet, pain)
Maintain adequate distance
Consider moving to a safe, low-stimulant environment
Use non-threatening verbal and non-verbal techniques (e.g. active listening, pictures, symbols)
Involve relatives or carers who are close to the patient
Consider advise from specialist elderly care psychiatrists or geriatricians
Consider involvement of the local delirium and dementia team

Question 19

Despite simple deescalation methods, patients with delirium may still pose significant psychological or physical harm to themselves and there may be risk of harm to others within the environment (e.g. patients, staff).

In these situations, the use of short-term pharmacological measures may be needed that is often referred to as rapid tranquillisation. Most hospitals set out local guidelines for the appropriate use of medications to manage severe behavioural abnormalities or agitation.

Two commonly used medications include:

Answer 19

Benzodiazepines (e.g. lorazepam)

Anti-psychotics (e.g. haloperidol, olanzepine)

Question 20

MCA

Answer 20

The Mental Capacity Act (MCA) is legal documentation that is designed to help protect and empower people that may lack the capacity to make decisions about their care. It applies to people 16+ years old. The legal framework essentially states that we should assume a person has capacity to make a decision unless proved otherwise. We cannot assume someone lacks capacity just because it is an unwise decision.

Question 21

Mental capacity should be assessed in two stages:

Answer 21

Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
Does the impairment mean the person is unable to make a specific decision when they need to?

Question 22

A person lacks capacity if they cannot do one or more of the following:

Answer 22

A person lacks capacity if they cannot do one or more of the following:

Understand the information relevant to the decision
Retain the information long enough to be able to make the decision
Use or weigh up information available to make the decision
Communicate their decision

Question 23

When a patient lacks capacity?

Answer 23

If someone does lack capacity, we treat them in their best interests with the least restrictive option of their basic human rights. As part of this process, we should involve people closest to the patient (e.g. next of kin) who can advocate for them when lacking capacity. If patients do not have someone, an independent mental capacity advocate (IMCA) can be requested.

Before deciding a patient lacks capacity, it is important we take all necessary steps to enable them to make a decision. This may include providing alternative options, using different methods of communication, involving an advocate or delaying a decision.

Question 24

Deprivation of Liberty Safeguarding

Answer 24

In some cases, if the least restrictive options placed on a patient deprive them of their liberty (e.g. using mittens, hospital bed rails or not allowing them to leave hospital) then we must apply for a deprivation of liberty safeguarding (DoLS).

A DoLS is a formal application to the local authority who arrange a formal assessment to decide on whether the deprivation of liberty is in the best interests of the patient and thus grant the legal authorisation.

Question 25

Recovery from an episode of delirium may take weeks to months.

Answer 25

Older patients who develop delirium are at an increased risk of having prolonged delirium with adverse outcomes. Patients with pre-exiting cognitive impairment has an acceleration in cognitive decline after an episode of delirium.

Importantly, delirium is associated with an increased mortality, length of hospital stay, incidence of dementia and admission to long-term care. There is an estimated 70% risk of death within the first 6 months after admission to accident and emergency with delirium.