Delirium

Question 1

Define Delirium and provide DSM criteria for diagnosis

Answer 1

A rapid onset acute confusional state characterized by marked inattention and fluctuations in consciousness level.
DSM:
1. disturbed consciousness i.e. reduced awareness of environment and reduced attention or arousal i.e. unable to maintain attention/shift attention when topic changed — test with counting backwards and may also be drowsy
2. change in cognition i.e. altered memory, reasoning or language OR altered perception e.g. hallucinations not attributable to dementia
3. disturbance develops over short period of time (hours/ days) and fluctuates during the course of the day (usually worst at night) and a disturbed wake-sleep cycle
4. evidence from the hx, examinations or investigations that delirium is a consequence of a medical condition, drug withdrawal or intoxication, medication,

Question 2

What are the associated features of delirium?

Answer 2

delusions (often paranoid) but tend to be fleeting and lacking in logic.

emotional changes (anxiety, fear, depression)

motor changes (slowness, restlessness, agitation)

hallucinations (often formed and animated)

• Aggression and restlessness may manifest as signs of such delusions/ hallucinations.
• Hypoactive or apathetic delirium is hard to spot: patient is quiet, withdrawn, lacks initiative and responds poorly to interaction.

Question 3

What is the prevalence of Delirium?

Answer 3

20% in general hospitals
patients with dementia are 5-10x more likely to develop delirium
Half of all delirium occurs in people with prior dementia, and two-thirds of people with dementia in general hospitals have delirium.

Question 4

What are the risks associated with Delirium?

Answer 4

increased mortality (1 year mortality following an admission with delirium is 40%) (2x more than matched controls)

prolonged hospital admission

higher complication rates

institutionalization

3x increased risk of developing dementia

Question 5

What are the risk factors for developing Delirium?

Answer 5

RF predisposing:
Dementia 
Fraility
Multiple comorbidities
Sensory impairment
>65

RF ppt:
Current Hip fracture (NICE)
Surgery
Drug initiation/ withdrawal
Acute brain disease
hypoxia 
metabolic abnormalities
systemic infection
Severe illness

Question 6

How might you prevent the development of Delirium?

Answer 6

1. Reduce environmental upsets- loud noises, bright lights, restraint
2. facilitate vision and hearing
3. promote night time sleeping
4. keep mobile and active
5. keep well fed and hydrated
6. keep oriented
7. Reduce medication, avoid anticholinergic drugs and opiates

Question 7

How would you describe a patient with hyperactive delirium?

Answer 7

A patient with increased motor activity and associated agitation, hallucinations and challenging behaviour.

This type of delirium is more likely to be recognised but patients often get treated inappropriately with sedating drugs.

Question 8

How would you describe a patient with hypoactive delirium?

Answer 8

A patient is less likely to be recognized as delirious with hypoactive delirium because they become withdrawn, apathetic, lethargic and have decreased motor activity. It is often confused with depression. It is the most common type of delirium and is associated with longer hospitalization and higher rates of complication e.g. pressure sores due to reduced mobility.

Question 9

What is particularly pertinent for the history of a delirious patient?

Answer 9

• onset and course of confusion
• symptoms suggestive of underlying cause
• previous hx of confusion
• co-morbities
• drug and alcohol hx
• med history partic recent changes
• sensory deficits
• functional status
• social circumstances incl family and services

Question 10

What are the components to the examination of a delirious patient?

Answer 10

1. Consciousness: GCS
2. Cognitive function: AMT
3. NICE Recommend: CAM short confusion assessment method that looks at 4 domains-
   - Acute onset and fluctuating course
   - Inattention
   - Disorganised thinking
   - Altered level of consciousness
4. Infection screen looking for pot sites of infection includ P sore areas
5. Assess nutrition and hydration status
6. Rule out Urinary Retention and constipation by Abdo examination and DRE, consider post void bladder scan
7. Neuro examination including speech
8. Mental State Examination