Delirium Flashcards
What increases the incidence of delirium?
Age, severity of illness, presence of pre-existing cognitive impairment
What is delirium?
An acute and fluctuating disturbance in attention and cognition, often accompanied by a change in consciousness. Typically reversible and frequently seen in the elderly, particularly in inpatient settings
What are the causes of delirium?
- D: drugs and alcohol
- E: eyes, ears and emotional disturbances
- L: low output state
- I: infection
- R: retention (urine or stool)
- I: ictal (related to seizure activity)
- U: under-hydration/ under-nutrition
- M: metabolic disorders
- S: subdural haematoma, sleep deprivation
Which drugs can lead to delirium?
Anti-cholinergics
Opiates
Anti-convulsants
Recreational
What low output states can lead to delirium?
Myocardial infarction
ARDS
Pulmonary embolism
Congestive heart failure
COPD
Which metabolic disorders can lead to delirium?
Electrolyte imbalance
Thyroid disorders
Wernicke’s encephalopathy
How can delirium present?
- Disorientation
- Hallucinations
- Inattention
- Memory problems
- Change in mood or personality
- Disturbed sleep
Patients can be hypoactive or hyperactive and these presentations can fluctuate over time
How do dementia and delirium differ?
Favouring delirium:
- Acute onset
- Impairment of consciousness
- Fluctuation of symptoms: worse at night, periods of normality
- Abnormal perception (eg. illusions and hallucinations)
- Agitation, fear
- Delusions
Favouring dementia:
- Gradual onset
- Stable consciousness level
- Progressive decline in cognitive function
How do delirium and psychosis differ?
Psychosis may present with hallucinations and delusions, but usually with preserved orientation and memory
What are the investigations for delirium?
Comprehensive physical examination and infectious screen
Additional investigations guided by clinical suspicion based on history and examination and may include:
- Lab tests: FBC, U&Es, LFTs, TFTs, urinalysis, blood cultures
- Imaging: CT/MRI, chest x-ray, uss abdomen
- ECG: rule out arrhythmias or ischaemic changes that could cause hypoperfusion
What is the management of delirium?
Focusses on treating the underlying cause, non-pharmacological strategies are the first line:
- Providing an environment with good lighting
- Maintaining a regular sleep-wake cycle
- Regular orientation and reassurance
- Ensuring patient’s glasses and hearing aids are used if needed
What pharmacological interventions would be considered?
In patients who are extremely agitated and potentially a danger to themselves or others, small doses of haloperidol or olanzapine (anti-psychotics) can be considered
Why is haloperidol the first line pharmacological therapy for delirium?
Rapid onset of action and short half-life, making it easy to titrate and adjust based on the patient’s response
Which pharmacological therapies should be used to manage a patient with delirium and Parkinson’s?
Benzodiazepines such as Lorazepam
Anti-psychotics can lead to anti-dopaminergic effects causing extra-pyramidal side effects
What are the characteristics of delirium tremens?
- Agitation
- Rapid onset of confusion
- Tremor
- Sweating (autonomic hyperactivity)
- Visual hallucinations (tending to be small animals or insects)
- Rarely, seizures
