Delirium

Question 1

What questions do you want to ask about a patient presenting with Delirium?

Answer 1

Does he have dementia?

Is he more confused than normal?

When did this start? Sudden (Days/hours)? Gradual? (weeks/months)

Any other recent changes?

Question 2

What is Delirium?

Answer 2

Abrupt onset

Change in cognition

Fluctuating

Inattention / distractible

Circadian rhythm disturbance, emotional dysregulation, psychological dysregulation

A disturbance in attention, with reduced ability to focus, sustain, or shift attention. This disturbance in consciousness might be subtle, initially presenting solely as lethargy or distractibility, and might be frequently dismissed by clinicians and/or family members as being related to the primary illness.

Question 3

What is change in cognition?

Answer 3

hallucinations/perceptual changes – people might be suspicious/actively hallucinating/or noticing things in the corner of their eye

Question 4

How does delirium present differently to dementia?

Answer 4

Delirium will fluctuate over a period of hours/day – this is different to dementia!

Question 5

Tools for Dx of Delirium

Answer 5

CAM
4AT
DSM - 5

Question 6

Subtypes of Delirium + how common they are

Answer 6

Hyperactive (25%)
Hypoactive (65%)
Mixed (10%)

Question 7

What % of the community has delirium?

Answer 7

1-2%

Question 8

What % of the community over 85y/o presents with delirium?

Answer 8

14%

Question 9

How many hospital patients present with delirium?

Answer 9

up to 1/3 of patients

Question 10

What % of ITU admissions have delirium ?

Answer 10

30%

Question 11

What problems rise when thinking about Hypoactive delirum?

Answer 11

Hypoactive delirium is under-identified, in recent study >58.6% of patients had a hypoactive delirium.

We don’t identify it because Hypoactive patients are easy to look after – they are drowsy, stay in bed and do not ‘cause cahos’. However hypoactive delirium has the highest mortality and puts patients at risk of pressure sores, dehydration and deconditioning.

More common the more frail a patient is: In a study before of >65s 62% of patients with moderate frailty (slowed up – needing assistance with ADLs, not completely dependent) were found to have a delirium (in an inpatient setting). Whereas only 6.9% of those with mild frailty had a delirium.

Question 12

who is at risk of developing delirium?

Answer 12

Pre-existing brain pathology
Elderly
Severe illness
Frail patients
Infection or dehydration
Visually impaired
Polypharmacy
Alcohol excess

Question 13

Why is delirium a problem?

Answer 13

Longer hospital stays
Increased mortality
Anxiety and distress
Morbidity – pressure areas, dehydration, malnutrition, falls
More likely to require 24hr care
Identification improves management
8 x more likely to develop dementia

Question 14

Precipitants of Delirium

Answer 14

P- pain
I- Infection
N- nutrition
C - constipation
H - hydration

M- medication
E - environment

PLUS bladder

Question 15

Ix / Examination for Delirium

Answer 15

U&E, FBC, CRP, Haematinics, Calcium profile, LFTs, Thyroid

Infection? - CXR, Urine MC&S, Blood cultures

PR examination

Hydration assessment

Collateral history

Question 16

Triggers for delirium

Answer 16

Acute Medical Illness:
Infections
Hypoxia
Thyroid dysfunction
Organ failure
Trauma
Electrolyte Imbalance
Dehydration
↓↑sodium
Hypercalcaemia

Pain
Urinary Retention
Faecal impaction
Drug/alcohol withdrawal

Environment
Catheters/Cannulas
Poor Sleep
Procedures

Drug Side Effects :
Opioids
Steroids
TCAs
Anti-parkinsonian drugs
Anticholinergics

Question 17

Management of delirium patients

Answer 17

Re-orientation, reassurance, Clocks/calendars
Hydration and nutrition
Hearing aids and glasses
Maintain regular bowel movements
Avoid catheters, cannulas, tubes where possible
Avoid restraint, cot sides and sedation where possible*
Medication review

*May be appropriate if risk to self or others, discuss with a senior