Delirium Flashcards
Briefly define delirium.
Also known as acute brain failure, delirium is an acute syndrome characterised by altered consciousness, attention and cognitive function levels.
Explain the symptoms of delirium in relation to hyperactivity and hypoactivity.
Hyperactivity is more likely to be detected by healthcare professionals and involves combativeness, aggression and bizarre behaviour.
Hypoactivity is more commonly seen in elderly patients and involves withdrawal, quiescence, and listlessness symptoms. Patients can be mistakenly labelled as ‘pleasantly confused’ or suffering from depression.
Outline the cognitive, psychiatric and behavioural symptoms of delirium.
Cognitive – inattention, memory impairment, disorientation
Psychiatric – paranoia, delusions, hallucinations, illusions, affective liability
Behavioural – agitation or hypoactivity, resistance to care, sleep-wake disturbances
State the risk factors of delirium (hint: MISTE)
Metabolic - hyponatraemia, hypoglycaemia, hypoxemia, dehydration
Infection - UTI, pneumonia
Structural - subarachnoid haemorrhage, urinary retention
Toxic - drugs (analgesics, TCAs, antiarrhythmics, beta-blockers)
Environmental - being in a hospital or ED
Provide non-pharmacological options for the prevention and management of delirium.
- Ensuring a safe, comfortable and secure environment.
- Re-orientation of patients to place, time, and people if possible.
- Minimise noise and bright lights.
- Minimise staff changes.
- Provide reassurance to patient and family.
- Maintain adequate hydration.
- Limit catheters and restraints.
- Implement non-pharmacological sleep regimens.
Explain the role of drug therapy in treating delirium.
Drug therapy is reserved for patients who are at risk of harming themselves or others (e.g. by pulling out essential medical devices or lines)
Drug treatment is understudied, with only a few small trials to guide management.
Explain when Benzodiazepines would be considered in delirium.
Primarily indicated for delirium caused by alcohol or benzodiazepine withdrawal.
Explain the role of antipsychotics in the therapy of delirium.
Haloperidol is the first-line option for delirium unresponsive to non-pharmacological management. Small trials have shown antipsychotics improve hyperactive symptoms such as agitation, restlessness, thought and perceptual disturbance and shorten the duration of delirium.
Consider the DSM criteria for delirium.
Inattention – disturbance of consciousness (i.e. reduce clarity of awareness of environment), with reduced ability to focus, sustain or shift attention.
Disorganised thinking – a change in cognition (e.g. memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia.
Fluctuate time course – the disturbance develops over a short period (hours to days) and tends to fluctuate over the course of a day.
Explain the prognosis of a patient with delirium.
Patients with delirium are at an increased risk of adverse outcomes compared with patients without delirium – these risks are greater for some groups.
Elderly patients with delirium are 1.3-1.4 times more likely to die six months after discharge than non-delirious patients.
Critically ill patients with delirium are 3.2 times more likely to die than non-delirious.
30% more likely to develop dementia.
40% chance of full recovery*
Explain the mechanism of Haloperidol in delirium.
Antagonises cortical dopamine (D2) receptors, inhibiting the effects of dopamine, and disinhibits acetylcholine leading to acetylcholine increase and enhance cholinergic neurotransmission.
State the potential side effects of Haloperidol
Extrapyramidal effects, cardiovascular effects, QT prolongation, metabolic effects, reduced bone mineral density, and menstrual disturbances.
