Delirium Flashcards
Define delirium
- An acute, transient and global organic disorder of the CNS functioning resulting in impaired consciousness and attention
- Acute confusional state
3 types of delirium
hypoactive (40%)
hyperactive (25%)
mixed (35%)
Hypoactive delirium
Most common! But usually goes unrecognised (what Dr Eltrafi said)
Lethargy, decreased motor activity, sleepiness, apathy
Confused w/ depression
Hyperactive delirium
Agitation, irritability, restlessness, aggression
Hallucinations + delusions
confused w/ psychoses
Mixed delirium
Both hypo + hyperactive subtypes (signs of both)
Epidemiology delirium
- Most common complication of hospitalisation in elderly
* 2/3 of delirium occur in pts w/ pre-existing dementia
Aetiology delirium
HE IS NOT MAAD
• Hypoxia: resp failure, MI, CFF, PE
• Endocrine: thyroid (hyper + hypo), hyper/hypoglycaemia, Cushing’s
• Infection: UTI, pneumonia, encephalitis, meningitis
• Stroke + other intracranial events: stroke, ^ ICP, intracranial haemorrhage, SOL, head trauma, epilepsy (post-ictal), intracranial infection
• Nutritional: ↓ thiamine/nicotinic acid/vit B12
• Others: severe pain, sensory deprivation (E.g. leaving the person w/out their glasses or hearing aids), relocation (unfamiliar environments), sleep deprivation
• Theatre (post-operative): anaesthetic, opiate analgesics + other post-operative complications
• Metabolic: hypoxia, electrolyte disturbance (e.g. hyponatraemia → remember caused confusion in the COFE pt), hypoglycaemia, hepatic impairment, renal impairment
• Abdominal: faecal impaction, urinary retention, malnutrition, urinary retention, bladder catheterisation
• Alcohol: intoxication + withdrawal (delirium tremens
• Drugs: BDZs, opioids, anticholinergics, anti-parkinsonian (levodopa), corticosteroids, digoxin
Risk factors for delirium
Older Age (65+) Multiple co-morbidities Dementia Physical frailty Renal impairment Male Sensory impairment (E.g. blind, deaf…) Previous episodes Recent surgery Severe illness (e.g. CCF) Polypharmacy
CFs of delirium
Acute onset + fluctuating course (worse at night)
DELIRIUM
- Disordered thinking
- Euphoric, fearful, depressed or angry
- Language impaired: rambling speech, repetitive, disruptive
- Illusions, delusions (transient persecutory or delusions of misidentification), hallucinations (tactile or visual)
- Reversal of sleep wake pattern (tired in day + hyper-vigilant at night)
- Inattention
- Unaware/disorientated: disorientated to time, place, person (revealed by AMT/MMSE?)
- Memory deficits
Other: sleep disturbances, mood disturbance, psychomotor disturbances
MSE Delirium
- Appearance + behaviour → hypo- or hyperalert, agitated, aggressive, purposeless behaviour, … depends on the type of delirium
- Speech → incoherent, rambling
- Mood → low mood, irritable, anxious
- Thought → confused, ideas of reference (believing that innocuous events or mere coincidences have strong personal significance), misinterpretations
- Perception → illusions, hallucinations (visual), misinterpretations
- Cognition → disorientated, impaired memory, reduced concentration/attention
- Insight → poor
DDx
Dementia, mood disorders (depression or mania), late onset schizophrenia, dissociative disorders, thyroid disease (mimic hyper or hypoactive delirium)
ICD-10 dx of delirium
- Impairment of consciousness
- Global disturbance in cognition
- Psychomotor disturbance
- Disturbance of sleep-wake cycle
- Emotional disturbances
- ABC, consciousness level (GCS), vital signs, nutritional/hydration status
- Examinations: CV, respiratory, abdominal (inc. rectal exam) + neurological
Ix delirium
SIMILAR TO DEMENTIA SCREEN
1. Urinalysis (UTI)
- Bloods: FBC (infection), U+Es (electrolyte disturbance), LFTs (alcoholism, liver disease), calcium (hypercalcaemia), glucose, CRP, TFTs, B12/folate, ferritin
- ECG (MI/ACS?)
- CXR (chest infection)
- Infection screen: blood cultures + urine culture (MSU)
- Ix’s based on Hx/exam:
a. ABG (hypoxia)
b. CT head (head injury, intracranial bleed, CVA)
c. LP (meningitis)
d. EEG (epilepsy) - Diagnostic/monitoring questionnaires:
a. Confusion Assessment Method (CAM) → DIAGNOSIS → simple test for delirium/confusion; good sensitivity and specificity; 2/3 of: acute onset + 1fluctuating course, 2inattention (100 minus 7 backwards) + 3disorganised thinking (test by speech) or altered level of consciousness (GCS/ABPU)
b. Other (COGNITIVE ASSESSMENT – for progress) → AMT (can use to check improvement), MMSE
Treatment delirium
- Treat the cause (infection, electrolyte disturbance, stop drugs, laxatives [faecal compaction], analgesia for pain, catheter for urinary retention…)
- Reassurance + re-orientation
a. Reassure pts (reduces anxiety)
b. Remind pt of time, place, day and date regularly (reduce disorientation) - Provide appropriate environment
a. Quiet + well-lit room
b. Consistency in care + staff
c. Reassuring nursing staff
d. Encourage presence of friend/family member
e. Optimise sensory acuity (glasses, hearing aids, clocks, calendar) - Managing disturbed, violent or distressed behaviour
a. Encourage good fluid intake
b. Pay attention to continence
c. NOT FIRST LINE: oral low-dose [as usually old] haloperidol
d. Avoid BDZs (unless delirium due to alcohol withdrawal) → although they are still given → use short acting lorazepam over diazepam (stays in system shorter period)
e. Referral to COE consultant - Early OT/PT involvement, avoid sedation, review everyday (MMSE, AMT)
Medical rx
- Avoid anti-psychotics in Lewy Body dementia + Parkinson’s (as ^ extra-pyramidal signs)
- Haloperidol (or risperidone)
- Lorazepam (regular low dose)
