Delirium Flashcards
What is delirium?
It is an acute confusional state, and is common in hospitalised patients (up to 45% of over-65s in hospital)
How is delirium defined according to ICD-10?
An aetiologically non-specific syndrome characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour,, emotion and sleep-wake cycle, that is transient and of fluctuating intensity
Which drugs can commonly cause delirium? (12)
- Alcohol
- Opiates
- Sedatives
- Anticholinergics
- Diuretics
- Steroids
- Digoxin
- Anticonvulsants
- Lithium
- TCAs
- MAOIs
- L-dopa
…and polypharmacy
Which metabolic disorders can cause delirium? (6)
- Renal failure
- Hepatic failure
- Respiratory failure
- Cardiac failure
- Electrolyte imbalances
- Dehydration
What are the infective causes of delirium? (5 - tons more)
- UTI
- Pneumonia
- Sepsis
- Endocarditis
- HIV
etc.
What are the neurological causes of delirium? (5)
- Stroke
- SAH
- Head injury
- Space-occupying lesion
- Epilepsy
What are the others causes of delirium that aren’t necessarily medically related? (5)
- Stress
- Sleep deprivation
- Change in environment
- Urinary retention
- Constipation
What is the typical pattern of delirium in a 24 hour period?
In many cases the course is diurnally fluctuating, with the patient relatively settled during the daytime and most agitated in the evening (sundowning), and in cases of hypoactive delirium, they may not be agitated at all
In terms of consciousness, how does this differ between dementia and delirium?
In delirium it is altered, whereas in dementia it is usually clear
What are the first-line investigations for someone with suspected delirium? (7)
- Psychiatric history
- Mental state examination
- Cognitive assessment
- FBCs, U&Es (LFTs, TFTs, glucose, thiamine level, blood drug screen)
- Urinary dipstick, MSU (sputum samples, blood cultures, LP)
- CXR (AXR, CT head, MRI head)
- ECG (EEG)
What simple measures can be taken to prevent onset of delirium? (6)
- Ensuring sensory aids e.g. hearing aids/glasses are in place
- Encouraging fluids/nutritional intake and correcting electrolyte imbalances
- Rationalising drug charts
- Encouraging mobilisation
- Encouraging family members to spend time at the bedside
- Clocks, calendars and familiar objects from home can be brought in
What is the drug of choice to manage the symptoms of delirium?
Haloperidol
If the delirium is caused by alcohol or benzodiazepines, what is the drug of choice to help with agitation or psychosis?
A benzodiazepine
What are the complications of delirium? (7)
- Prolonged hospital stay (and thus increased risk of infections)
- Accelerated cognitive decline
- Aspiration pneumonia
- Fluid and electrolyte imbalance
- Malnutrition
- Falls
- Injuries
What are the three subtypes of delirium?
- Hyperactive
- Hypoactive
- Mixed
How does hyperactive delirium tend to present? (4)
- Inappropriate behaviour
- Hallucinations
- Agitation
- Restlessness, wandering
How does hypoactive delirium tend to present? (4)
- Lethargy
- Reduced concentration
- Reduced appetite
- Withdrawn and quiet
Although the pathophysiology of delirium is not fully understood, what are the mechanisms thought to be involved? (3)
- Cholinergic deficiency
- Dopaminergic excess
- Inflammation
Although the precipitation factors/causes of delirium have been addressed, what are the predisposing risk factors for delirium? (9)
- Older age
- Cognitive impairment (e.g. dementia)
- Frailty
- Significant injuries e.g. hip fracture
- History of alcohol excess
- Sensory impairment
- Poor nutrition
- Lack of stimulation
- Terminal phase of illness
Name two warning signs for delirium?
- Falling
2. Loss of appetite
What is the confusion assessment method (CAM) criteria for diagnosing delirium? (4)
- Confusion that has developed suddenly and fluctuates
- Inattention - ask if the person is easily distracted and has difficulty in focussing attention
- Disorganised thinking (unclear flow of ideas, change subject unpredictably)
- Altered level of consciousness
What is the DSM-IV criteria for delirium? (4)
- Confusion that has developed over a short period of time and fluctuates
- Disturbance of consciousness
- Change in cognition
- Evidence from history, examination and investigations which is consistent with delirium and cannot be attributed to another diagnosis
According to NICE CKS, what investigations need to be carried out in someone with suspected delirium and briefly why? (13)
- Urinalysis (infection/hyperglycaemia)
- Sputum culture (chest infection)
- FBC (infection/anaemia)
- Folate/B12 (vitamin deficiency)
- U&Es (AKI/electrolyte disturbance)
- HbA1c (hyperglycaemia)
- Calcium
- LFTs (hepatic failure/rule out hepatic encephalopathy)
- Inflammatory markers (CRP)
- Drug levels (drug toxicity e.g. lithium)
- TFTs (hyper/hypothyroidism)
- CXR (e.g. pneumonia, heart failure)
- ECG (cardiac conditions e.g. arrhythmias)
What are the differentials for delirium? (6)
- Depression
- Dementia
- Mental illness
- Anxiety
- Thyroid disease
- Charles Bonnet syndrome
