Delirium

Question 1

What is delirium?

Answer 1

acute confusional state
-acute onset, develops rapidly over hours-days
-serious medical problem, much more than a nuisance effect

Question 2

What does delirium affect?

Answer 2

global cognitive function
-memory, orientation, language, perception, visuospatial skills

Question 3

Asides from confusion, what are some other features of delirium?

Answer 3

psychomotor disturbance
altered sleep-wake cycle
emotional lability

Question 4

What is the definition of delirium as per the DSM-5?

Answer 4

acute onset
disturbances in attention, awareness, and cognition
attributable to an underlying cause
fluctuates in severity

Question 5

Describe the prevalence of delirium.

Answer 5

affects ~11-42% of all medical inpatients
more common in older adults
-1/3 of medical inpatients > 70 years of age
-most common surgical complication

Question 6

What is the significance of delirium?

Answer 6

poor prognostic indicator
associated with:
-2 x increased risk of death
-2.5 x increased risk of discharge to higher level of care
-12.5 x increased risk of developing dementia
increased length of hospitalization (5-10 days)
sustained functional decline 6 months after admission

Question 7

What is the etiology of delirium?

Answer 7

underlying vulnerability + stressors

Question 8

What are some predisposing factors for delirium?

Answer 8

increased age
dementia
functional impairment (baseline)
multimorbidity
others
-decreased hearing/vision, mild cognitive impairment, depression, alcohol/drug use

Question 9

What are some precipitating factors for delirium?

Answer 9

drugs
surgery/trauma
infection
pain
anemia
exacerbation of chronic disease
bedridden

Question 10

What are examples of drug that can increase risk of delirium?

Answer 10

the worst:
-anticholinergics (TCAs, 1st gen AH, muscle relaxants, 1st gen APs, benztropine)
-benzodiazepines
-opioids
also bad:
-anticonvulsants (CBZ, phenytoin, topiramate, gabapentinoids)
-dopamine agonists
-amantadine
-THC products
less likely but possible:
-corticosteroids
-psychoactive NSAIDs (indomethacin)
-digoxin
-CBD products

Question 11

What is the most useful bedside method for diagnosing delirium?

Answer 11

Confusion Assessment Method (CAM)
requires 1+2 with either 3 or 4:
1. acute changes in mental status with fluctuations
2. inattention
3. disorganized thinking
4. altered level of consciousness

Question 12

What are the subtypes of delirium?

Answer 12

hyperactive delirium subtype
-combative, agitated, restless
mixed delirium subtype
-fluctuating between the other two
hypoactive delirium subtype
-drowsy, somnolent, unarousable

Question 13

Differentiate delirium and dementia.

Answer 13

delirium:
-onset: acute (hours-days)
-course: fluctuating
-decreased level of consciousness: may be present
-attention: impaired
-hallucinations: common
dementia:
-onset: chronic (months)
-course: progressive
-decreased level of consciousness: absent
-attention: preserved until end-stage
-hallucinations: rare until later stages

Question 14

What are some strategies to prevent delirium?

Answer 14

orientation
-use calendars, clocks
-encourage use of glasses, hearing aids
-accommodate visitors
-promote regular sleep-wake cycle
mobilization
-physical therapy
-avoid unnecessary lines, catheters, restraints
medication review
-reassess use of high-risk medications
-medication/substance withdrawal
-pain control, bowel + bladder function
hydration and nutrition
-maintain or optimize

Question 15

How is delirium managed?

Answer 15

1. identify and manage underlying cause(s)
   -most important step
2. initiate or continue supportive strategies
3. medications
   -only if necessary, smallest role

Question 16

What are some supportive strategies for treating delirium?

Answer 16

treat the underlying condition
manage pain and other symptoms
encourage mobilization
re-orientation, cues
maintain sleep-wake schedule
de-escalation for agitated individuals
system-level interventions:
-minimize time spent in ED
-trained volunteers to calm, provide re-orientation
-low beds
-non-slip floors or socks

Question 17

When can pharmacological therapy be considered for delirium?

Answer 17

patient is in significant distress from their symptoms
patient poses a safety risk to self or others
patient is impeding essential aspects of care

Question 18

How are medications used for delirium?

Answer 18

off-label

Question 19

What is the first line pharmacological option for delirium?

Answer 19

antipsychotics

Question 20

How do we choose an antipsychotic for delirium?

Answer 20

based on side effect profile, patient factors, and availability
similar efficacy among agents

Question 21

How are antipsychotics dosed for delirium?

Answer 21

start with low doses and titrate to effect q30min
prn doses thereafter

Question 22

Which class of medications should be avoided in a patient experiencing delirium?

Answer 22

benzodiazepines
-except in alcohol-withdrawal delirium, terminal delirium

Question 23

What is the conventional drug of choice for delirium?

Answer 23

haloperidol
-if longer duration of treatment needed, switch to atypical to decrease EPS risk

Question 24

What is the benefit of atypical antipsychotics compared to typicals?

Answer 24

decreased EPS risk BUT increased orthostasis risk

Question 25

Which atypical antipsychotic is the most anticholinergic?

Answer 25

olanzapine

Question 26

Which atypical antipsychotic is used for delirium in patients with Parkinsons or Lewy Body Dementia?

Answer 26

quetiapine
-least DA blockade

Question 27

What is a black box warning of atypical antipsychotics?

Answer 27

dementia

Question 28

What is the role of the pharmacist in delirium prevention and management?

Answer 28

deprescribe medications known to increase delirium risk
assess for and manage pain, constipation
ensure judicious use of antipsychotics for delirium