Delirium

Question 1

def delirium

Answer 1

Clinical syndrome, typically in the elderly
Alteration of attention, consciousness, and cognition w/ ↓ ability to focus, sustain or shift attention

Question 2

timeline of delirium

Answer 2

acute onset
fluctuates during the day

Question 3

epi of delirium

Answer 3

MC surgical cx in elderly

Question 4

what is DIMES-R for delirium?

Answer 4

they are common etiologies for delirium

Drugs ➔ intoxication, withdrawal ➔ sedating meds/polypharmacy
Infections ➔ UTI is MC in elderly, skin/soft tissue, blood
Metabolic ➔ glucose, lytes, Cr, liver, CO2, TSH, B12 etc.
Structural ➔ stroke, hemorrhage, seizures, neoplasm ➔ consider neuroimaging
Retention ➔ fecal impaction of urinary retention

Question 5

what are the three main ways delirium can present?

Answer 5

• hyperactive: increase agitation and sympathetic activity w/ incoherent speech and disorganized thoughts ➔ hallucinations (MC visual), delusions +/- combative/uncoop behaviour
• hypoacitve: increase sleepiness and decrease arousal ➔ may be mistaken as fatigue or depression
• mixed

Question 6

s/s of delirum

Answer 6

• hyperactive s/s
• hypoactive s/s
• sleep-wake cycle disturbances ➔ sundowning, increase s/s at night
• cog deficits
• emotional labiltity
• altered psychomotor activity

Question 7

RF for delirium

Answer 7

↑ age (>70Y)
Dementia
Functional disabilities
♂
Poor vision and hearing
Mild cog impairment
Alcohol use disorder and lab abnormalities

Question 8

assessment tool for delirium?

Answer 8

Confusion assessment method (CAM)
- requires the presence of 1+2 + (3 or 4)
1. acute changes in mental status + fluctuating
2. inattention ➔ focusing attention/easily distractible
3. disorganized thinking ➔ flow of ideas
4. ALOC - hyperactive or hypoactive

Question 9

how to w/u delirium?

Answer 9

1. review chart ➔ collateral + last seen normal
2. review meds ➔ polypharm ➔ BEER’s criteria
3. Confusion Assessment Method (CAM)
4. p/e ➔ neuro + targeted
5. initial labs: cbc, glucose, urine, urea/Cr, lytes/extended lytes, LFTs, abdo XR or bladder scan re: retention
6. DIMES-R work-up

Question 10

how to tx delirium?

Answer 10

1. underlying cause
2. consult medicine
3. consider antipsychotic (haldol) for agitation or psychotic symptoms ➔ benzos only if haldol doesn’t work; we wanna avoid physical and chemical restraints
4. non-pharma (consider before pharm): help with reorinteation ➔ glasses, hearing aids, calenders, good sleep, orientation activtiies, family education to recog s/s of delrium