Delirium Flashcards
What is Delirium?
Acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute illness, surgery, trauma or drugs.
What is the most common mental health problem in hospitalised patients over the age of 65?
Delirium
What types of Drugs are known to cause Delirium?
Anticholinergic agents,
Anticonvulsants,
Alcohol,
Illicit drugs,
Sedatives (benzodiazepines)
What types of Metabolic disorders can cause Delirium?
AKI
Hypoglycaemia
hypothyroid
B12/Folate
Calcium
What are some systemic causes of Delirium?
Infection
Neoplastic disease
Vascular Disease
Electrolyte disturbance
Urinary retention/ Constipation
What are General features of Delirium?
- Rapid Onset
- Transient and Fluctuating course
- Inattention / decreased awareness
- Features are not explained by another pre-existing, established or evolving neurocognitive disorder or coma
- Lasts Days - Months depending on underlying cause.
What are the different types of Delirium?
- Hyperactive Delirium
- Hypoactive Delirium
- Mixed Delirium
What is Hyperactive delirium?
In An Elderly patient (+/- Cognitive Impairment), Recent Injury e.g. fractured Hip
- Sudden Onset New Confusion, agitation, restlessness.
- Fine during the day.
- Overactive in the evening, awake overnight with disruptive behaviours and delusions / hallucinations of persecution.
What kind of Delusions/ Hallucinations may Patients with Hyperactive delirium have?
Delusions / Hallucinations of Persecution.
What is Hypoactive Delirium?
In An Elderly patient (+/- Cognitive Impairment), Recent Injury e.g. fractured Hip
- Becomes suddenly quiet, withdrawn, sleepy.
- Fluctuates through the day
- Doesn’t eat, drink, care.
- Often Misdiagnosed as Depression.
What is the most common type of Delirium seen?
Mixed Delirium
What is Mixed Delirium?
Mixed delirium refers to a subtype of delirium in which features of both hyperactive and hypoactive delirium are present.
Patients Vary Wildly through a 24hr period.
Often labeled as Behavioural Delirium.
Asleep all day and awake all night with very disruptive behaviours
What kind of examinations should be done when meeting a patient with Delirium?
- History if possible (often collateral)
- Full examination (Neuro is important, MSK to look for Injury)
- Assess Consciousness
- Basic observations (Don’t Forget Blood Sugar)
What is the Diagnostic Criteria for Delirium?
- Impairment of consciousness
- Disturbance of cognition
- Psychomotor disturbance
- Disturbance of sleep-wake cycle
- Emotional disturbance
What Screening tools are used in Delirium?
4-AT, Confusion assessment method.
At what age should all patients be screened for delirium on admission to hospital?
> 65 years
- Important as a baseline even if patient does not present with delirium on admission.
What Investigations should be done on a patient with Delirium?
Wide range for the wide range of possible casues.
- Medication review
- Bloods
- ECG
- Imaging (depending on presentation - e.g. bladder scan, CT head)
- Specialist Tests (EEG, LP etc may play a role)
What is the non-medical management of patients with Delirium?
Identify and treat cause
Manage environment and provide support:
- Reality orientation
- Bright sideroom
- Correct Sensory impairments
- “unsafe” objects removed
Food chart, Fluid chart, Bowel Chart
Review patient frequently
What is the main duration for Delirium to be present?
1-4 weeks
- often longer in elderly
- minority can become chronic
When should Pharmacological management be considered in Delirium?
Reserved for when patients do not respond to Non-medical methods.
- 1st line - Haloperidol 500mg orally
(IM if unable to take oral Meds)
Alcohol / Sedative withdrawal, remember regular prescribing of benzodiazepines thereafter.
When is Haloperiold Contraindicated in the Tx of Delirium?
When the patient has a Hx of Parkinson’s or LBD.
What should be given in Patients with Delirium when haloperidol is Contraindicated?
Lorazepam 500 micrograms - 1mg orally
What is the major Complication of Delirium?
Under-Treatment of recognised cases has an adverse impact on length of stay, morbidity and mortality
What is Charles-Bonnet Syndrome?
A syndrome Characterised by complex visual hallucinations in individuals with Visual impairment. (Wet AMD)
Particularly in Elderly patients.
Have Patients got insight with Charles-Bonnet Syndrome?
Yes they are usually aware that the hallucinations are not real.
Patients typically have no other cognitive or Psychiatric symptoms.
