Delirium

Question 1

An 83 year old woman is admitted following a fall. She becomes acutely confused the following day and is very disruptive on the ward. How would you assess and manage her?

Answer 1

Introductory
Given the acute onset of confusion and disruptive behaviour post-fall, I am concerned about the onset of a hyperactive delirium in this elderly patient. With delirium, there are a number of common triggers which I would like to consider in my assessment including;
- UTI, and other infective (LRTI, etc)
- trauma
- medications
- drugs/withdrawal

There are some important differentials to consider in this patient as well, these include other organic causes as well as primary psychotic conditions
Organic
- electrolyte derangements (hypercalcaemia, hyper/hyponatraemia, etc)
- intracerebral infection
- dementia
- vascular (stroke, TIA)
Psychotic
- schizo
- brief psychotic
- delusion
- mania

Question 2

Delirium - History

Answer 2

History
- may be limited from patient, attempt collateral from fam/nurse to gauge condition prior to current presentation
- Take the ABC approach:
A - Antecedent
B - Behaviour
C - Consequences
- sx: confusion, agitation, fluctuating course, disorientation. Current status on the ward (hyper vs hypoactive)
- associated: LUTS, other infective, cognitive decline, recent hx of cognitive impairments, past psych history
- PMHx, medications, allergies
- SNAP

Question 3

Delirium - Examination

Answer 3

Examination
May be hindered by degree of patient’s agitation and non-compliance
- General appearance + vital signs
- assess cognition (MOCA, RUDAS, MMSE)
- Delirium tools (CAM screening tool, 4AW)
- hydration assessment
- systems review for underlying cause

Question 4

Delirium - Investigations

Answer 4

Investigations
Depending on setting, would defer if patient not compliant/too agitated and not appropriate (or if late at night, etc)
Bedside: UA, ECG, BSL
Bloods: UEC, LFT, CRP/ESR, cultures if febrile, FBC
Imaging: bladder scan for urinary retention

Question 5

Delirium - Management

Answer 5

Management
Definitive
- reverse underlying cause (UTI, DVT, etc)
Pharmacological:
- Haloperidol 0.5mg or 0.25 if frail old lady, chart as once-only medication
- avoid Benzo’s

Supportive

• keep in same room
• frequent obs
• encourage familiars visitation, keep things from home to remain oriented
• approach directly
• allow to roam in ward if safe
• frequent re-orientation, patient and family education, reassurance for the patient