Delirium Flashcards
What is delirium?
Also known as ‘acute confusional state’
Acute (hr-d onset), fluctuating syndrome of disturbed:
- Consciousness
- Attention
- Cognition
- Perception
Outline the DSM-5 criteria for delirium
All of:
- Disturbance in attention and awareness from baseline
- Acute onset (typically hours-days); fluctuating severity
- Additional cognitive disturbance
- eg. memory deficit; disorientation; language; perception
- Not better explained by another neurocognitive disorder
- Evidence of precipitating event responsible for disturbance
Describe the illness course of delirium
- Sudden onset
- Fluctuating course
- Gradual resolution: up to 6-months
- Following effective treatment of underlying cause
List the three clinical presentations of delirium
- Hyperactive delirium
- Hypoactive delirium
- Mixed delirium
Describe hyperactive delirium
- Psychomotor agitation
- Increased arousal
- Inappropriate behaviour
- Hallucinations: commonly visual
- Delusions: commonly persecutory
- Restlessness and wandering are common
Describe hypoactive delirium
- Psychomotor retardation
- Appear quiet or withdrawn
- Lethargy
- Reduced appetite
- Excess somnolence (drowsiness)
Describe mixed delirium
Combination of hyperactive and hypoactive delirium with varying presentation over time
Name three predisposing factors for delirium
- Elderly or very young
- Pre-existing dementia
- Sensory impairment: eg. visual or hearing
- Post-op (especially cardiac)
- Alcohol abuse; benzodiazepine-dependent; poor nutrition
- Serious and/or multiple illnesses; polypharmacy
- Lack of stimulation
Provide five precipitating factors for delirium
Delrium is usually multifactorial
- UTI; chest infections; infected pressure sore; sepsis
- Hyperglycaemia; hypoglycaemia; electrolyte abnormalities
- MI; heart failure; stroke; intracranial bleed
- Thyroid dysfunction; PE; COPD exacervation
- Urinary retention; constipation; malnutrition
- Severe uncontrolled pain; major surgery
- Medication changes; alcohol intoxication or withdrawal
- eg. opiods; benzodiazepines; steroids
- Hospital admission; emotional stress; sleep deprivation
Name five complications of delirium
- High mortality (20% during admission, up to 50% at 1yr)
- Increased duration of stay
- Nosocomial infections
- Institutionalisation and/or re-admission
- Increased risk of:
- Dementia
- Falls
- Pressure sores
- Continence problems
- Functional impairment; distress for self/carers
What is the association between delirium and dementia?
Delirium causes neuronal death ➔ Independent cause (3x more likely) for dementia development and progression
Pre-existing dementia is a predisposing factor for delirium
Request three investigations for suspected delirium
- Cognitive testing: 4AT; MoCA; Addenbrooke’s
- Urinalysis
- Sputum culture; CXR
- FBC; CRP
- U+Es; calcium
- HbA1c
- TFTs
- Haematinics: eg. B12; folate
- EEG
What are the management principles for delirium
- Identify and treat underlying causes
- Environmental and supportive measures
- Avoid sedation unless severely agitated or a risk
- Regular clinical review and follow-up
Name four environmental and supportive measures in the management of delirium
- Maintain hydration and nutrition
- Physical environment
- eg. Safe environment; good lighting; noise reduction; clocks and calendars; hearing and visual aids
- Human environment
- eg. Same staff; firm clear communication; routine; prevent transfer
- Control of distressing physical symptoms
- Avoid unnecessary procedures
- Promote healthy sleep patterns
Name three physical environmental factors for optimal management of delirium
- Safe environment
- Adequate lighting
- Noise reduction
- Clocks and calendars
- If appropriate, hearing and visual aids
