Delirium

Question 1

What tool can you use for a quick cognitive assessment?

Answer 1

AMTS10 or AMT4

Question 2

What are the questions in AMTS?

Answer 2

• Age
• Current time
• Recall - remember an address
• Current Year
• Current location
• Recognise two people
• DoB
• Years of WW1
• current monarch
• Count sequentially back from 20 to 1

Question 3

What score implies cognitive impairment?

Answer 3

<8

Question 4

How is delirium diagnosed?

Answer 4

Confusion Assessment Method or 4AT

Question 5

What should be checked in patient with suspected delirium?

Answer 5

Cognition (MMSE), inattention, conscious level, thinking, collateral history (baseline)

Question 6

What is CAM positive?

Answer 6

• Acute onset and fluctuating course PLUS
• Inattention (counting backwards or reduced attention during interview) AND EITHER
• Disorganised thinking OR Altered level of consciousness

Question 7

What does 4AT assess?

Answer 7

Alertness, AMT4 (age, DoB, year, current place), Attention (December backwards), acute and fluctuating course

Question 8

What are 1st line investigations for suspected delirium? (11)

Answer 8

o	FBC
o	CRP
o	U&Es
o	Ca2+
o	TFTs
o	LFTs
o	Glucose
o	CXR
o	ECG
o	Pulse Oximetry 
o	Urinalysis

Question 9

What are 2nd line investigations?(5)

Answer 9

ABGs, CT head, EEG, specific culture

Question 10

What should be noted in an examination?

Answer 10

• pyrexia and any signs of infection in the chest, skin, urine or abdomen
• oxygen saturation
• signs of alcohol withdrawal, such as tremor or
  sweating
• any neurological signs.

Question 11

What are predisposing factors to delirium?

Answer 11

Old age, dementia, frailty, sensory impairment, polypharmacy, renal impairment

Question 12

What are precipitating factors for delirium?

Answer 12

Intercurrent illness, surgery, change of environment, dehydration, medications, sensory deprivation, pain, constipation, urinary retention, hypoxia, fever, alcohol withdrawal, urinary catheterisation, MI, infection, electrolyte imbalance

Question 13

Which drugs cause delirium?

Answer 13

• Opioid analgesics
• Drugs with anti-cholinergic properties
• Sedating drugs
• Corticosteroids

Question 14

What are four components of treatment?

Answer 14

• Treatment of underlying cause
• Environmental measures
• Pharmacological measure
• Prevention of complications

Question 15

What are the complications of delirium?

Answer 15

o	Falls
o	Pressure sores
o	HCAIs
o	Functional impairment
o	Incontinence
o	Over-sedation 
o	Malnutrition

Question 16

What are general measures of management?

Answer 16

• Reassurance and re-orientation
• increased nursing observation
• encourage mobility
• Regular monitoring of AMTS
• Follow up in community - increased risk of dementia

Question 17

What are first-line methods for managing distressed patients?

Answer 17

De-escalation methods with familiar staff/relatives/carers

Question 18

When are pharmacological measures indicated?

Answer 18

Last resort
• To prevent patient endangering themselves or others
• Allow essential investigations or treatment
• Relieve distress in a highly agitated patient

Question 19

What medications are used?

Answer 19

haloperidol (at 0.5mg orally or 1mg IM) or olanzapine.

Question 20

What treatment can be given to parkinson’s or lewy body dementia patients?

Answer 20

Lorazepam. Not haloperidol.

Question 21

What are the risks of delirium?

Answer 21

• Increased mortality
• Increased institutionalisation
• Increased complications
• Increased incidence dementia
• Increased length of stay

Question 22

What is hyperactive delirium associated with?

Answer 22

restlessness, agitation, heightened arousal and aggression.

Question 23

What is hypoactive delirium associated with?

Answer 23

associated with drowsiness, increased sleeping, quiet or withdrawn behaviour. Hypoactive delirium is often more difficult to identify, as are those with a ‘mixed’ picture. Classic hand movements. Carries higher mortality.