Delirium

Question 1

Define delirium

Answer 1

Acute fluctuating syndrome causing disturbed consciousness, attention, cognition, memory, behaviour and perception
AKA acute confusional state

Question 2

What are the types of delirium

Answer 2

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Hypoactive = lethargy, reduced concentration, reduced appetite, may seem quiet or withdrawn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

Question 3

What is the aetiology of delirium

Answer 3

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

Question 4

What are the risk factors for delirium

Answer 4

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

Question 5

What is the epidemiology of delirium

Answer 5

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

Question 6

What are the symptoms of delirium

Answer 6

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

Question 7

What are the differentials for delirium

Answer 7

Psychosis
Substance misuse
Thyroid disease
Dementia
Depression
Non-convulsive epilepsy

Question 8

What investigations should be done for delirium

Answer 8

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

Question 9

What is the CAM for delirium

Answer 9

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

Question 10

What is the management for delirium

Answer 10

1. Admit to hospital (if refusing → MCA)
2. Re-orientation
3. Ensure safe mobility
4. Normalise sleep-wake cycle
   + follow up within 24h of initial assessment and regularly until symptoms have resolved

Question 11

What are the re-orientation strategies used for delirium

Answer 11

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

Question 12

What is the management for challenging behaviour in delirium

Answer 12

1. Consider an underlying cause e.g. discomfort, thirst, need for toilet
2. Move the person to a safe, low-stimulation environment
3. Use verbal and non-verbal de-escalation techniques
4. If these measures fail: short-term pharmacological therapy - haloperidol for 1 week

Question 13

What are the complications of delirium

Answer 13

Increased mortality
Increased length of stay in hospitals → nosocomial infections
Increased risk of dementia
Falls
Pressure sores
Continence problems
Malnutrition
Functional impairment

Question 14

What is the prognosis for delirium

Answer 14

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