Delirium

Question 1

What is delirium?

Answer 1

Delirium is an acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma, or drugs.

Question 2

Main features of delirium?

Answer 2

Disturbance in attention

Change in cognition
(eg, memory deficit, disorientation, language disturbance, perceptual disturbance)

Question 3

Delirium develops over a long period of time. True/false?

Answer 3

False

Develops over a short period (usually hours to days) and tends to fluctuate during the day.

Question 4

Delirium is a serious medical condition associated with increased levels of morbidity and mortality. True/false?

Answer 4

True

Question 5

What is the % prevalence of delirium in acute adult general med wards?

Answer 5

20% prevalence

Question 6

What are the risk factors for delirium?

Answer 6

Elderly

Pre-existing cognitive impairment

Post-operative

Sensory impairment e.g. deaf/blind

Previous history of delirium

Drug/alcohol dependence

Depression

Polypharmacy

Multiple co-morbidities (e.g. frailty, Parkinson’s, cerebrovascular disease)

Critical care admission e.g. HDU/ITU

Question 7

What are the causes of delirium using the DELIRIUM mnemonic?

Answer 7

Drugs/medication

Electrolyte disturbance e/g/ hyponatraemia

Lack of drugs (withdrawal)

Infection

Reduced sensory input, pain

Intracranial e.g. stroke/subdural

Urinary retention/constipation

Metabolic e.g. acute kidney injury, hypoglycaemia, B12/folate

Question 8

Overall features of delirium?

Answer 8

Acute onset

Fluctuating course

Altered conscious level (may be hypo/hyperactive)

Inattention/decreased awareness

Disorganised thinking (may include psychotic features e.g. hallucinations, severe agitation)

Question 9

What are the 2 main subtypes of delirium?

Answer 9

Hyperactive and hypoactive

Question 10

Features of hypoactive delirium?

Answer 10

Withdrawn, apathetic, sleepy, coma

Question 11

Features of hyperactive delirium?

Answer 11

Agitated, aggressive, wandering

Question 12

Why does hypoactive delirium have a poorer prognosis?

Answer 12

Compared to hyperactive prognosis, hypoactive delirium is harder to spot and diagnose.

Question 13

A change in mood or personality is a notable feature of delirium. Some patients can display “sundowning”, what is this?

Answer 13

Sundowning is agitation and confusion worsening in the late afternoon and evening

Question 14

What is the screening tool used in the case of a possible delirium diagnosis?

Answer 14

4-AT score

Question 15

Components of the 4-AT score?

Answer 15

Alertness - drowsy or sleepy during assessment. Rated based on normal, slightly sleepy (for <10 seconds after waking then return to normal) and abnormal.

AMT4 - age, date, place (name of hospital or building), current year. 1 point awarded for each mistake up to 2.

Attention - can recite months of the year backwards. 7 or more seen as adequate.

Acute change or fluctuating course

Question 16

The higher the score on the 4-AT, the higher the chance of delirium as a diagnosis. True/false?

Answer 16

True

Question 17

Apart from the 4-AT score, what other investigations can be done for delirium?

Answer 17

Bedside - bladder scan, review medications, ECG (arrhythmias, ischaemic changes that could cause hypoperfusion) urine MC&S - you should not perform urine dipstick if >65 as they are less sensitive in this age group.

Bloods: FBC, urea and electrolyes, liver function tests, thyroid function tests, and blood cultures.

Imaging: chest X-ray, or ultrasound of the abdomen. Neuroimaging with CT or MRI head is reserved for those without a clear identifiable cause.

Question 18

Management of delirium?

Answer 18

Primarily focused on treating underlying cause.
Particularly using non-pharmacological management as first line including:

Providing an environment with good lighting

Maintaining a regular sleep-wake cycle

Regular orientation and reassurance

Ensuring the patient’s glasses and hearing aids are used if needed

Question 19

In the management of delirium, what therapy type is used first line?

Answer 19

Non-pharmacological therapy is used first line in the management of delirium

Question 20

For patients who are extremely agitated and potentially a danger to themselves or others, what pharmacological interventions may be used?

Answer 20

Small doses of haloperidol or lorazepam.

Olanzapine may also be considered however, these should be used with caution, especially in the elderly, due to the risk of side effects.

Question 21

What is a considerable risk for delirium?

Answer 21

Polypharmacy (patient being on multiple medications at one time)

Question 22

List of medications that could potentially lead to delirium?

Answer 22

Opioids – tramadol, MST, oramorph, codeine etc

Anticholinergics – amitriptyline, oxybutynin, solifenacin etc

Sedatives – benzos, sleeping tablets, anti-histamines (includes ranitidine!)

Psychotropic medications – lithium, anti-psychotics, anti-depressants (SSRIs)

Anti-epileptics – phenytoin, phenobarbital, carbamezapine

Cardiac medications – digoxin, anti-hypertensives

Steroids, NSAIDs

Anaesthetic agents

Withdrawal of medications/alcohol/nicotine

Parkinson medications – although NEVER stop these acutely without d/w PD specialist