Delirium Flashcards
Define delirium
Acute fluctuating syndrome causing disturbed consciousness, attention, cognition, memory, behaviour and perception
AKA acute confusional state
What are the types of delirium
Hyperactive= inappropriate behaviour, hallucinations, agitation, restlessness, wandering
Hypoactive = lethargy, reduced concentration, reduced appetite, may seem quiet or withdrawn
Mixed = signs and symptoms of both hyperactive and hypoactive subtypes are present
What is the aetiology of delirium
Infections: UTI, pneumonia, encephalitis
Metabolic disturbance: hypoglycaemia, electrolyte abnormality
Cardiovascular: MI, HF
Resp: PE
Neuro: stroke, encephalitis, subdural haematoma, neurosyphilis
Uro: UTI, urinary retention
GI: constipation, severe impaction, hepatic failure
Medication: opioids, benzos, anticholinergics, steroids, antihistamines, lithium, TCAs
Psychosicial: depression, sleep deprivation, visual or hearing impairment, emotional stress, change of environment
What are the risk factors for delirium
Advanced age (>65)
Cognitive impairment e.g. dementia
Frailty/Multiple comorbidities e.g. stroke or heart failure
Significant injuries e.g. hip fracture
Functional impairment e.g. immobility or the use of physical restraints such as cot sides
Iatrogenic events e.g. bladder catheterisation, polypharmacy, surgery
Alcohol excess
Sensory impairment e.g. visual impairment or hearing loss
Poor nutrition
Lack of stimulation
Terminal phase of illness
What is the epidemiology of delirium
Thought to affect up to 50% of older people >65 in hospital
10-30% of acute inpatients >65 have delirium on admission to hospital, up to 30% with new onset delirium after admission
80% on ICU develop delirium
50% have unrecognised delirium
What are the symptoms of delirium
Sudden change in behaviour (hours to days)
- Behavioural disturbance
- Personality change
- Psychotic features
- Fluctuating (may be lucid during the day, worse at night)
Altered cognitive function: disorientation, memory and language impairment, worse concentration, confusion
Inattention: easily distractable, difficulty focusing, moving attention from one thing to another
Disorganised thinkingL rambling, irrelevant conversation, unclear flow
Altered perception: paranoid delusion, hallucinations
Altered consciousness: sleep-cycle disturbance
Falls, loss of appetite
What are the differentials for delirium
Psychosis
Substance misuse
Thyroid disease
Dementia
Depression
Non-convulsive epilepsy
What are the signs of delirium on examination
Obs: ?fever, ?hypoperfusion (HR,BP), ?hypoxia
General: ? dehydration, ?cachexia
Cardio, resp, abdo, MSK, neuro, skin exam
MSE
What investigations should be done for delirium
Collateral history
Cognitive screening
Short-CAM or DSM-5 for diagnosis
Rule out organic:
Bedside: BM, urine dip, sputum culture, ECG
Bloods: FBC, B12/folate, U&Es, HbA1c, Calcium, LFTs, ESR/CRP, ABG/VBG, toxicology, TFTs
Others: CXR
What is the CAM for delirium
Confusion Assessment Method:
Confusion that has developed suddenly and fluctuates, and
Inattention
Disorganised thinking
Altered level of consciousness
Disorientation
Memory impairment
Perceptual disturbances
Psychomotor agitation
Psychomotor retardation
For a diagnosis of delirium by CAM, the patient must display:
1. Presence of acute onset and fluctuating discourse
AND
2. Inattention
AND EITHER
3. Disorganized thinking
OR
4. Altered level of consciousness
What is the management for delirium
- Admit to hospital (if refusing → MCA)
- Re-orientation
- Ensure safe mobility
- Normalise sleep-wake cycle
+ follow up within 24h of initial assessment and regularly until symptoms have resolved
What are the re-orientation strategies used for delirium
Regular cues e.g. explaining who they are and where they are
Easily visible and accurate clocks and calendars
Continuity of care from carers and nursing staff
Encouraging visits from family or friends and exposure to familiar objects
What is the management for challenging behaviour in delirium
- Consider an underlying cause e.g. discomfort, thirst, need for toilet
- Move the person to a safe, low-stimulation environment
- Use verbal and non-verbal de-escalation techniques
- If these measures fail: short-term pharmacological therapy - haloperidol for 1 week
What are the complications of delirium
Increased mortality
Increased length of stay in hospitals → nosocomial infections
Increased risk of dementia
Falls
Pressure sores
Continence problems
Malnutrition
Functional impairment
What is the prognosis for delirium
Has a fluctuating course, where recovery may be rapid or take weeks to months
‘Subsyndromal’ delirium (symptoms of disorientation, inattention, and memory impairment that do not fulfil the diagnostic criteria for delirium) may persist for up to 12 months
70% increased risk of death in the first 6 months if they have presented to the ED with delirium
Mortality rates in those diagnosed with delirium are 2x that of people with similar medical conditions who do not have delirium
Physical function may be impaired for 30 days or more after discharge in people who have developed delirium in hospital
