Delirium

Question 1

82F Betty, fine/independent at baseline, active etc., minimal meds in community, non-smoker, but 3-4SD/week. Husband died 5 years ago. Visited regularly by children and grandchildren. Recently had a fall and NOF and then is admitted. Now on ortho ward in a 4 person room, post-op day 4. She’s been confused and has had times where she’s drowsy during the day and also times where she’s been agitated and aggressive to co-patients and obviously confused. Wants to mobilise out of bed despite nurses’ objections. Also complaining of seeing small animals in her room. Now also calling out to her husband (who died 5y ago). It is currently 3AM and you’re night intern. The nurses call you, saying they think she has undiagnosed schizophrenia and suggests moving her to the psych ward. It’s 3am. (1) what are your ddx, and what are some likely causes? what do you think of the hypothesis that this is undiagnosed scz? (2) how to ax? (3) how to mx? (both non-pharm and pharm options), (4) what would you tell the nurses in response to their idea to move patient to psych ward?

Answer 1

Impression
Given age, fluctuating confusion, agitation, altered LOC; this is most likely a presentation of hyperactive/mixed delirium in the context of recent NOFF, rather than a psychiatric presentation. Of course, important differentials to consider include;

Organic
- Dementia
- Medication related
- 
Psychiatric (non-affective)
- delusional disorder
- schizophreniform
- schizophrenia

Priorities
- manage initially as delirium, undertake full psych assessment when appropriate

Question 2

Delirium - initial management

Answer 2

Initial management
Given 3am, would institute some temporising management initiatives to ensure patient safety and security until full assessment can be conducted:
- regular checking/observation, not for psych admission
- lower bed, bed rails to prevent falls
- if appropriate, take bloods to further investigate
- remove any unnecessary lines/tubes etc
- administer appropriate analgesia for NOFF, consider fascia iliaca block to reduce opioid requirement

If significant distress, consider pharmacological:
- antipsychotic (haloperidol 0.5mg PO) - single dose

Question 3

Delirium - History

Answer 3

History
- May require collateral history. Want to understand patient's baseline cognitive function
- HPI: 
- Past psych history: schizo
- fam history: psychiatric
- substance use
-

Question 4

Delirium - Examination

Answer 4

Examination

• General observation + vital signs
• neurological examination -> ?stroke
• fluid balance assessment
• MSE: appearance, behaviour, thought form+content

Question 5

Delirium - Investigations

Answer 5

Investigations

• Bedside: urine MCS, ECG, VBG, urine too screen
• Bloods: FBC, UEC, LFT, CRP/ESR, CMP,
• imaging: dependent on suspicions of various pathology, otherwise CXR,
• Other: 4AT rapid clinical assessment for delirium, or validated Confusion Assessment Method (CAM) scoring system

Question 6

Delirium - Management

Answer 6

Management

• prevention of delirium is better than management, so identifying at-risk patient and putting in place prevention strategies is important
• pharmacological intervention usually not required, once delirium identified, emplacing non-pharmacological strategies is typically all that is required.

Non-pharmacological

• keep patient in same room/ward
• encourage regular family visits, have homely comforts around
• approach patient front-on, educate patient and family about delirium
• avoid restraint and interventions which may lead to further agitation, remove any unnecessary lines and institute a medications review
• regular review and observation
• investigate for underlying cause