Delirium

Question 1

What is delirium?

Answer 1

Delirium is an acute, transient and reversible state of confusion, usually the result of other organic processes (infection, drugs, dehydration), the onset is acute and the cognition of the patient can be highly fluctuant over a short period of time. Impairment of consciousness

In OPIC self test –> acute onset confusion with hallucinations or illusions

Question 2

What are the types of delirium?

Answer 2

Hyperactive
Hypoactive
Mixed- where pts fluctuate between the 2

Question 3

Features of hyperactive delirium?

Answer 3

Agitation
Delusions
Hallucinations
Wandering
Aggression

Question 4

Features of hypoactive delirium?

Answer 4

Less well know and so often missed/ confused with delirium
Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention

Question 5

What can cause delirium?

Answer 5

CHIMPS PHONED
Constipation
Hypoxia
Infection
Metabolic disturbance (e.g. hyponatraemia from SSRIs)
Pain
Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic or renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)

Question 6

What do you need to rule out in a patient with ?delirium

Answer 6

Dementia
Depression (+/- psychosis)

Question 7

How do you take a hx from a pt with ?delirium?

Answer 7

Conversation wil provide clues if they’re confused
Provide reassurance
Ask the pt what they’re seeing/hearing experiencing

Collateral history (e.g. family, friends, nursing staff)
Medical notes (e.g. past medical history, current medications)

Useful information in the patient’s medical notes may include:
Past medical history (e.g. atherosclerosis, stroke, previous episodes of confusion, head injury, recent admissions)
Current medications: review for drugs that may cause or contribute to confusion (e.g. opiates)
Social history (e.g. how are they coping at home, excess alcohol, illicit drug use)

Question 8

What screening tools do we use for delirium?

Answer 8

4AT or AMTS

Question 9

What examinations do you do for a pt with delirium?

Answer 9

Full Neuro- motor and sensory
Look for head trauma
Suprapubic tenderness- UTI
Vital signs for any signs of infection/pain
GCS/AVPU
Asterixis- uraemia or encephalopathy

Question 10

What investigations would you do for a pt with ?delirium

Answer 10

• Confusion screen bloods -FBC, U+E, LFT, TFT, Coag screen, Bone prolife (for calcium), B12 and folate, blood cultures
• Urinanalysis (dipstick + culture + signs)
• CT head
• CXR

Question 11

What do you test for in a confusion screen?

Answer 11

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)

Question 12

What are the types of management for delirium?

Answer 12

TREAT UNDERLYING CAUSE
General
Environmental

Question 13

What are some general supportive management techniques for delirium?

Answer 13

• consistent nursing and medical team,
• gentle re-orientation,
• calm and consistent care,
• regular introductions of yourself and your role,
• clear and concise communication.
• Ensure the patient has access to aids such as glasses, hearing aids and walking sticks where appropriate.
• Enable the patient to do what they can for themselves – independent washing, dressing, eating, toileting and other activities may still be possible with varying levels of encouragement.

Question 14

What are some environmental management techniques for delirium?

Answer 14

Ensure there is access to a clock and other orientation reminders for the day, date and time.
Have some familiar objects where possible (e.g. having photographs available, using the patient’s own clothes/washcloths).
Involve the family, friends and/or carers in the care of the patient.
Control the level of noise around the patient.
Ensure lighting is adequate and the temperature is ambient.

Question 15

What is important to consider in terms of medication for pts who have delirium?

Answer 15

• Avoid unnecessary medications wherever possible.
• Persistent wandering and delirium are not absolute indications for sedation.
• Aim to keep the patient safe by the least restrictive method.
• The use of medications, particularly those for sedation, can worsen delirium.
• Haloperidol (oral, IV or IM) is usually the first-line medical option, starting with a 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).6

Question 16

If you HAVE to use medication to sedate pts with delirium, what would you use?

Answer 16

Haloperidol (oral, IV or IM) is usually the first-line medical option, starting with a 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)

Question 17

How do you follow up a pt with delirium?

Answer 17

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

Question 18

What are life threatening causes of delirium? (induction lec on BB)

Answer 18

Question 19

Define acute confusion (BB)

Answer 19

Acute deficit in thinking, short term memory and orientation in time/place with reduced awareness