Delirium

Question 1

What is delirium

Answer 1

An acute, fluctuating change in mental state with inattention and disorganised thinking

Question 2

The DSM-5 notes that in order to be diagnosed with delirium, a patient must show all 4 of the following features

Answer 2

• Impaired attention - reduced ability to focus, sustain or shift attention
• Change in cognition - e.g. memory deficit and disorientation
• Disturbance develops over a short period of time (usually hours-days)
• Evidence that the disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication or substance withdrawal

Question 3

State the 3 clinical subtypes of delirium

Answer 3

• Hyperactive
• Hypoactive
• Mixed

Question 4

Describe hyperactive delirium

Answer 4

patient might have:
* heightened arousal
* restlessness
* agitation
* hallucinations
* inappropriate behaviour

Question 5

Features of hypoactive delirium

Answer 5

• lethargy
• reduced motor activity
• incoherent speech
• withdrawn

Question 6

Which subtype of delirium is most common

Answer 6

Hypoactive delirium

Question 7

Give 5 RFs for delirium

Answer 7

• > 65
• Dementia/ cognitive impairment
• Visual/ hearing impairment
• Polypharmacy
• frailty or multimorbidity
• significant injury e.g. hip fracture
• Dehydration

Question 8

Give 6 precipitants for delirium

Answer 8

• severe pain
• Infection e.g. UTI
• metabolic - hypercalcaemia, hypo/hyperglycaemia, dehydration
• Constipation
• alcohol withdrawal
• change of Environment

Question 9

Give 4 examples of drugs that can result in delirium

Answer 9

• anti-Parkinson’s drugs (co-careldopa, pramipexole)
• anticholinergics
• opiate
• Tricyclic antidepressants

Question 10

What investigations should be done for suspected delirium

Answer 10

• FBC, U&E, LFTs
• Urinalysis, blood cultures, ABG
• CXR - pneumonia? Congestive HF etc ?
• CT head

Question 11

How is delirium managed

Answer 11

• treat underlying cause and modify environment
• Re-orientation, reassurance and de-escalation
• Distressed/ high risk - low dose haloperidol for <1 week
• Parkinson’s: Try careful reduction of Parkinson meds, quetiapine or clozapine are preferred

Question 12

Give 4 differentials for delirium

Answer 12

• Dementia
• drug withdrawal
• psychosis
• Mania