Delirium Flashcards
Delirium
Acute, transient and reversible state of confusion
Types of delirium
Hyperactive delirium
Hypoactive delirium
Clinical features of hyperactive delirium
Agitation
Delusion
Hallucinations
Wandering
Aggression
Clinical features of hypoactive delirium
Lethargy
Slowness
Excessive sleepiness
Inattention
Aetiology and risk factors of delirium (CHIMPS PHONED)
Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness
Prescriptions (iatrogenic)
Hypothermia/pyrexia
Organ dysfunction (hepatic/renal)
Nutrition
Environmental changes
Drugs
Assessment of delirium
- History - direct history, collateral
- Look at notes - PMH, DH, SH
- Cognitive assessment - AMTS (can also do ACE-III or MMSE)
- Clinical examination - Obs, GCS, evidence of head trauma, source of infection (abdo, resp), asterixis
- Confusion screen
What is included in confusion screen
Bloods
-FBC (e.g. infection, anaemia, malignancy)
-U&Es (e.g. hyponatraemia, hypernatraemia)
-LFTs (e.g. liver failure with secondary encephalopathy)
-Coagulation/INR (e.g. intracranial bleeding)
-TFTs (e.g. hypothyroidism)
-Calcium (e.g. hypercalcaemia)
-B12 + folate/haematinics (e.g. B12/folate deficiency)
-Glucose (e.g. hypoglycaemia/hyperglycaemia)
-Blood cultures (e.g. sepsis)
Urinalysis
- dipstick, MC&S
Imaging
- CTH, CXR
Definitive management of delirium
Treat underlying cause
Supportive management of delirium
- Least restrictive method
- Ensure access to aids (e.g. glasses, hearing aids, mobility etc)
- Promote independence
- Ensure access to clock + orientation to time and place
- Familiar objects
- Control noise level
- Ensure lightning is adequate and temperature is ambient
Pharmacological management
- 1st line: Haloperidol (oral, IV or IM) (low dose in the elderly (0.5mg))
- If benzodiazepines are to be used, lorazepam is first-line (0.5mg starting dose) due to its rapid onset and short half-life (see the NICE guidance for further management).
- The use of medications, particularly those for sedation, can worsen delirium
Advice
- Families/carers need to be aware that delirium can continue for a period of time after the cause has been treated
- Information should be given to those surrounding the patient on the management of any residual disorientation or inattention
- Follow-up is advisable
Prevention
- Avoid drugs known to precipitate delirium (e.g. opiates and benzodiazepines)
- Identify patients at higher risk of developing delirium and observe them closely for early signs of delirium
- Assess other factors which may induce or exacerbate delirium (e.g. pain control, drugs etc)6
Employ supportive/environmental management approaches for all patients, regardless of delirium risk
