Delirium

Question 1

What is delirium?

Answer 1

Delirium, also known as an ‘acute confusional state’, is an acute, fluctuating syndrome of disturbed consciousness, attention, cognition, and perception.

Question 2

Is delirium reversible?

Answer 2

Yes, delirium is often reversible and typically secondary to an underlying medical condition, substance intoxication or withdrawal, or medication side effects.

Question 3

Who is most affected by delirium?

Answer 3

Delirium is a common and serious condition, especially in hospitalised and elderly patients.

Question 4

What are the two types of presenations for delirium? Which one is more common?

Consider cognitive, perceptual, emotion/psychomotor changes and sleep

Answer 4

Hyperactive delirium: Agitation, restlessness, mood lability, wandering, hypervigilance, aggressive

Hypoactive delirium (most common but often missed): Lethargy, reduced motor activity, person may seem withdrawn, lack of interest, excessively sleepy, lack of focus. Worse outcomes with returning to normal cognitive levels.

Clinical Features of delirium
* Acute onset and fluctuating course: Symptoms can vary over the course of a day, often worsening at night.
* Disturbance in attention and awareness: Difficulty focusing, sustaining, or shifting attention.
* Cognitive impairment: Disorientation, memory deficits, language disturbances, impaired concentration and slow responses.
* Perceptual disturbances: Hallucinations (auditory or visual), illusions, paranoid delusions, misperceptions
* Altered sleep-wake cycle: Fragmented sleep, daytime drowsiness.
Emotional disturbances and psychomotor features: Anxiety, fear, irritability, apathy. Agitation or reduced motor activity.

Question 5

What are the consequences of delirium?

Answer 5

Delirium is associated with increased morbidity, mortality, and length of hospital stay.

Increases risks of dementia, delirium and causes functional decline.

Question 6

What are some common causes of delirium? Which mnemonic is used?

Answer 6

The causes of delirium are multifactorial and include infection, medications, recent surgery, metabolic imbalances, hypoxia, substance abuse, neurological disorders, discomfort, environmental factors, and chronic illnesses.

PINCH ME: Pain, Infection, Nutrition, Constipation, Medication, Environment

Question 7

What infections can cause delirium?

Answer 7

Any Infection, especially urinary tract infections (UTIs) and pneumonia.

Question 8

What medications can contribute to delirium?

Answer 8

Medications such as strong analgesics, anti-cholinergics, steroids, Parkinson’s medication, and those causing adverse effects or polypharmacy can contribute to delirium.

Including alcohol

Question 9

What metabolic imbalances can lead to delirium?

Answer 9

Metabolic imbalances such as dehydration, electrolyte disturbances - commonly sodium fluctuations, hypercalcaemia, hypoglycaemia, and deranged LFTs, TFTs.

Hepatic encephalopathy, hyper/hypothyroidism

Question 10

What role does hypoxia play in delirium?

Answer 10

Hypoxia due to respiratory or cardiac failure can contribute to the development of delirium.

Question 11

What neurological disorders are associated with delirium?

Answer 11

Neurological disorders such as stroke, seizures, head injury, and intracranial bleeds are associated with delirium.

Question 12

What discomfort factors can lead to delirium? Consider things related to constipation

Answer 12

Constipation, urinary retention.

Discomfort from skin wounds/ulcers/blisters, catheters, and soiled nappies can lead to delirium.

Question 13

What environmental factors can contribute to delirium?

Answer 13

Environmental factors such as sleep deprivation, sensory deprivation or overload, and unfamiliar surroundings can contribute to delirium.

Question 14

What chronic illnesses are linked to delirium?

Answer 14

Chronic illnesses, particularly advanced organ failure (renal, hepatic), are linked to delirium.

Question 15

What may cause pain in delirium?

Answer 15

• Chronic illnesses/ underlying disease – e.g. abdominal pain
  
  • Orthopaedic fractures eg. Hip
  • Neurologic conditions
    ○ Head injury
    ○ Mass, stroke, epilepsy, dementia
• Surgery
• Devices: catheters, cannulas

Question 16

What are some risk factors for developing delirium? List at least 5 (unmodifiable, acquired, iatrogenic)

Answer 16

Several risk factors increase the likelihood of developing delirium:
* Age: Older adults, particularly those over 65 years.
* Pre-existing cognitive impairment: Dementia, mild cognitive impairment.
* Comorbidity/frailty
* Prexisting psychiatric illness e.g. depression
* Polypharmacy: particularly psychoactive drugs, alcohol
* Sensory impairments: Vision or hearing loss.
* Dehydration and malnutrition
* Previous delirium
* Environmental factors: Changes in environment, poor lighting, lack of familiar objects.
* Surgery and medical procedures e.g. catheterisation
Major injuries e.g. hip fracture

Question 17

What are some preventative measure for patients who are at higher risks of delirium?

Include screening/monitoring, and interventional methods

Answer 17

• Early detection and monitoring of precipitators e.g. looking for and treating infections, bowel and bladder monitoring, avoiding constipation, manage nutrition and fluid intake, sleep hygiene.
• Address cognitive impairment/disorientation with supportive care e.g. appropriate lighting, use of clocks, address sensory impairment
• Assess for pain and medication review. Avoidance of polypharmacy.

Question 18

How is it typically diagnosed?

Answer 18

4AT score: Alertness (Alertness, confusion, response to stimuli, movement), Attention (recite the months in a backward order), AMT-4 (cognition), acute/fluctuation

If the 4AT indicates delirium then can be diagnosed by someone with the relevant expertise after making a final diagnosis

Question 19

What are some bedside tests to investigate for underlying causes of delirium?

Answer 19

• Glucose (e.g. hypoglycaemia/hyperglycaemia)
• ECG/ABG: cardiac abnormalities, hypoxia, metabolic disturbances
• Urinalysis/urine culture:
  ○ A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of delirium.
  ○ Look for other evidence supporting the diagnosis (WCC↑/supra-pubic tenderness/dysuria/offensive urine/positive urine culture).

Question 20

What blood tests may be requested to investigate causes of delirium? List 7.

Answer 20

• FBC (e.g. infection, anaemia, malignancy)
• Inflammatory markers
• U&Es (e.g. hyponatraemia, hypernatraemia)
• Calcium (e.g. hypercalcaemia)
• LFTs (e.g. liver failure with secondary encephalopathy)
• Coagulation/INR (e.g. intracranial bleeding)
• TFTs (e.g. hypothyroidism)
• Blood cultures (e.g. sepsis)
• folate/B12

Question 21

What are considerations for ordering CT scans or chest X-rays?

Answer 21

Changing environments may increase risk of disorientation and worsen/trigger delirium.

Question 22

What are supportive measures to manage delirium?

Answer 22

○ Ensure adequate hydration and nutrition. Encourage mobility, hydration, nutrition (dentures clean)
○ Maintain a regular sleep-wake cycle.
○ Reorient the patient frequently using clocks, calendars, and familiar objects.
○ Minimise sensory impairments with appropriate use of glasses and hearing aids.
Ensure a calm, well-lit environment, reducing noise and avoiding unnecessary room changes

SIGN guidelines: checklist of communicating with patient relatives

Question 23

If delirium is persistent, what medications could be tried?

Answer 23

• Haloperidol 0.5mg in elderly, 2.5-10mg(start low dose to avoid extra-pyrimidal/dystonic reactions)
• Lorazepam
• Risperidone