Delirium

Question 1

Who is at increased risk of delirium?

Answer 1

> 65y
past or present cognitive impairment and/or dementia
current hip fracture
severe illness

Question 2

Risk factors for delirium

Answer 2

older
has memory problems
has poor hearing or eyesight
have recently had surgery
have a terminal illness
have an illness of the brain eg. infection, stroke, head injury
have previously had delirium

Question 3

Causes of delirium

Answer 3

DDELIRIUMS
drugs - intoxication
drugs - withdrawal
environmental factors (lack of assistive devices, sleep/wake cycle, immobilisation)
low oxygen
infection
retention of urine or stool
intracranial abnormality (seizure, stroke, tumour, trauma)
underhydration/undernutrition
metabolic (electrolytes, glucose, thyroid, deficiency)
sleep disturbances

Question 4

What is the PINCHME mnemonic for and name the components

Answer 4

to identify potential causes of delirium

Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment

Question 5

Delirium subtypes

Answer 5

hyperactive delirium
hypoactive delirium
mixed delirium

Question 6

Hyperactive delirium presentation

Answer 6

combative
agitated
restless

Question 7

Hypoactive delirium presentation

Answer 7

lethargic
sedated
stupor

Question 8

Define delirium

Answer 8

aetiologically non-specific syndrome characterised by concurrent disturbances of:
- consciousness and attention
- perception
- thinking
- memory
- psychomotor behaviour
- emotion
- the sleep-wake cycle

rapid onset
transient
fluctuating intensity (usually diurnally)

Question 9

Delirium signs and symptoms

Answer 9

reduced awareness of the environment
may result in:
- inability to stay focussed on a topic
- getting stuck on an idea rather than responding to questions/conversation
- easily distracted by unimportant things
- being withdrawn

poor thinking skills (cognitive impairment)
may present as:
- poor memory
- disorientation
- difficulty speaking or recalling words
- rambling or nonsense speech
- trouble understanding speech
- difficulty reading or writing

behaviour changes:
- hallucinations
- restlessness
- slowed movement/lethargy
- disturbed sleep

emotional disturbances:
- anxiety, fear or paranoia
- depression
- euphoria
- apathy
- personality changes

Question 10

Management of delirium

Answer 10

try and prevent
find cause and treat

provide lighting during waking hours and have clock/calendar

telling person where they are, who they are and who you are
introduce cognitively stimulating activities
facilitating family/friend visits
ensure their normal aids are available
promote good sleep patterns and hygiene

Question 11

When should pharmacological management be used in delirium?

Answer 11

distressed and/or risk to themselves and others and verbal de-escalation and other non-pharmacological methods have failed

Question 12

What pharmacological treatment is available for delirium?

Answer 12

avoid benzo if possible

haloperidol - start low dose, <1week, avoid in LBD and Parkinson’s

follow up and assess for dementia if unresolving

Question 13

Dementia vs delirium

Answer 13

onset = delirium onset short, dementia onset longer and worsens

attention = delirium pt will struggle to maintain attention, dementia pts are generally alert

fluctuation = delirium sx can be diurnal, dementia memory and thinking skills remain pretty similar throughout day with some fluctuation

Question 14

Delirium prognosis

Answer 14

2/3 recover in a week
may persist

Question 15

What legal frameworks are available for detention of a patient with delirium in hospital?

Answer 15

MCA and DOLs
MHA