Delirium

Question 1

Delirium definition

Answer 1

A temporary global mental change of organic cause. Commonly with altered cognition, attention, psychomotor behaviours and abnormal sleep-wake cycle.

Question 2

Causes of delirium

Answer 2

• C - constipation
• H - hypoxia/hydration (lack of/urinary retention)
• I - infection
• M - metabolic (glucose, K, Na, Ca)
• P - pain
• S - Sleeplessness
• P - perscriptions
• H - hypothermia/pyrexia
• O - organ dysfunction (renal/hepatic)
• N - nutrition
• E - Environmental change
• D - drugs (OTC, illicit, alcohol, tobacco, other peoples)

Question 3

Differences between hyper and hypo active delirium

Answer 3

Hyperactive

• High activity
• Uncooperative
• Combative

Hypoactive (most common)

• Sleeping all the time on and off
• Unable to sustain attention when awake and usually falls back to sleep
• Misses meals medication and appointments
• Doesn’t ask for care or attention

Can also be mixed (second most common)

Question 4

History in delirium

Answer 4

May be collateral

PC

HPC

• Classic sx: memory, awareness, attention, disordered thinking, hallucinations, altered sleep
• Should be acute
• Should be fluctuating

PMH

• Previous diagnosis of dementia
• Cardiac/resp issues (stroke, hypoxia)
• Infections
• Bowels - constipation
• DM
• Pain
• Previous delirium

PSHx

• Post - op

DH - VERY IMPORTANT

• Recent change
• Recreational
• OTC
• Other people

FHx

• Cognitive impairment e.g. dementia, delirium

SHx

• Change in environment
• Sleep
• Smoking and alcohol
• Nutrition - are they eating?
• Other SHx stuff: home set up, mobility, carers,

AMT (more than 8 unlikely delirium)

1. Age
2. Time to the nearest hour
3. Location
4. Remember address
5. Date of birth
6. Current PM
7. Start of WW1
8. Current year
9. Ask previous address
10. Identify two people e.g. nurse doctor
11. Count 20-1

Risk

• To themselves
• From others
• To others
• To property

Question 5

Delirium DDs

Answer 5

• Lewy body dementia (as it also fluctuates)
• Step down in vascular dementia
• Decompensation of existing dementia
• Disorder of alertness
• Disorder of communication
• Post ictal confusion
• Primary psych disorder

Question 6

Confusion bloods and reason for each

Answer 6

• FBC - infection, anaemia
• CRP
• U&E - dehydration, hyper/po natraemia, kalaemia,
• LFT - liver failure
• INR - intracranial bleeding
• TFT - hypo/er thyroid
• Calcium - hypercalcaemia
• B12 folate - anaemia + deficiency
• Glucose - hyper/o glycaemia

Question 7

Investigations in delirium

Answer 7

• Obs
  
  • HR, BP, SATS, Temp
• Imaging
  
  • CT head, CXR
• Confusion bloods
• Urine dip
• Blood cultures if sepsis suspected

Question 8

Management of delirium

Answer 8

• Treat any causes found
• Treat symptoms
• Support
  
  • Fluids +/- electrolytes
  • Nutrition
  • Calm environment with clock
• Avoid drugs if possible
• Make a solid discharge plan as 1 episode means they are likely to happen again. Involve carers and family

Question 9

Drugs associated with delirium

Answer 9

• Sedatives - benzos
• Anti convulsants - barbituates
• Anti parkinsons - benztropine
• Analgesics
• Antihistamines
• GI agents - H2 blockers, anti-spasmodics
• Antinausae
• Antibiotics
• Psychiatric - TCAs, lithium
• Cardiac meds - B blockers, anti arrythmias
• MM relaxants
• Steriods

Question 10

Cognitive assessment in delirium

Answer 10

• AMT
• MSE