Delirium

Question 1

Background

Answer 1

Delirium - transient, usually reversible, cerebral dysfunction and manifests clinically with a wide range of neuropsychiatric abnormalities.
- Can be called encephalopathy or acute confusion state. severe cases are medical emergency.

• Is confused with depression, dementia, schizophrenia, old age

Subtypes:
- Hyperactive delirium - with inappropriate behaviour, hallucinations, or agitation.
- Hypoactive delirium - with lethargy and reduced concentration and appetite.
- Mixed delirium - with signs and symptoms of both.

Risk factors:
>65, Cognitive impairment, frailty/comorbidities, Injuries, functional impairment, alcohol abuse history, poor diet, terminal illness, lack of stimulation, sensory impairment, iatrogenic event.
- Precipitate: Illness, Body system disorders, meds (benzos, opiates, polypharmacy), alcohol.

Question 2

Signs & Symptoms

Answer 2

• Inability to maintain coherent stream of thought/action
• Impaired attention/arousal
• Distractible
• Disorganised thinking
• Altered social behaviour - mood changes, inappropriate
• Altered perception
• Altered consciousness level - disturbed sleep wake cycle
• Falling and loss of appetite

Behaviour changes happen over time (hours to days)

Question 3

Diagnosis/Assessment

Answer 3

Made by short confusion assessment (Shirt-CAM) or DSM5.
- Take history from person and informed observer (family/carer) = find factors, symptoms etc
- Examine person - Temp, BP, BG, HR, Pulse oximetry. Check body systems
- Confirm diagnosis by CAM, DSM5 or 4 As

THEN ASSESS PRECIPITATING FACTORS

Question 4

Treatment

Answer 4

1st step = Identify and address underlying causes, provide environmental and supportive measures, provide pharmacological management of symptoms and maintain fluid and nutrition.

• Patients with alcohol toxicity or withdrawal include thiamine in treatment.
• Environment mods = Memory cues = calendar, clocks, family photos.
• Sensory deficits should be corrected - glasses or hearing aids

Risperidone, olanzapine, and quetiapine relieve symptoms while minimising AE.
- Haloperidol can be used for acute psychosis
- Risperidone can be used for behaviour disturbance

Question 5

Follow up

Answer 5

• Review within 24 hours of initial assessment and regular until symptoms resolved.