Delirium Flashcards
What is delirium?
It is a syndrome involving an acute confusional state.
DSM says:
-disturbance to attention- difficult to hold their attention, short term memory problems
- change in cognition
-develops over short period of time and fluctuating
-disruption of wake/sleep
-changed not better explained by alternative- dementia- particularly vascular, coma, stroke
- underlying systemic cause
What is pathopyhsiology of delirium?
Brain decompensates as can’t cope with stress
What are the causes of delirium?
- anti cholinergic drugs
- steroids
- opioids
- benzos
- urinaru retention
- systemic inflammation
- pain
- constipation
- infection
- hypoxia- most common cause pneumonia
- dehydration
- metabolic eg ca, lft, tsh, na
- toxin
- withdrawal- alcohol is delirum tremens
What are the risk factors for delirium?
sensory impairment, cognitive impairment (functional capacity), immobile (decreased ability to orientate self), Previous delirium, polypharmacy, old age, severe illness, hip fracture
What are the differentials for delirium?
dementia, depression, psychiatric disorder, dysphasia, epilepsy, stroke
What are some examinations for delirium?
Examine the person:
obs; TFT, LFT, U+E, FBC, glucose, calcium, haematinics
Check vital signs including temperature, blood pressure, heart rate, capillary refill time, finger-prick blood glucose, and pulse oximetry — to identify fever, hypoperfusion, hyperglycaemia, hypoglycaemia, or hypoxia.
Carry out a general examination to identify precipitating factors such as:
Respiratory conditions, for example chest infection, pulmonary embolus, heart failure, or chronic obstructive pulmonary disease.
Cardiovascular conditions, for example myocardial infarction and heart failure.
Abdominal conditions, for example acute abdomen, constipation, faecal loading (carry out a rectal exam if possible if impaction is suspected), urinary retention, and urinary tract infection.
Musculoskeletal conditions, for example hip fracture.
Neurological conditions, for example stroke, subdural haematoma, epilepsy, encephalitis, or drug intoxication.
Skin conditions, for example infection, pressure sores, or ulcers.
Electrolyte imbalance such as dehydration, acute kidney injury, hypercalcaemia, or hyponatraemia.
Endocrine and metabolic disorders such as cachexia, thiamine deficiency, or thyroid dysfunction.
Sensory impairment, for example impacted ear wax, ill-fitting or non-functioning hearing aids, and spectacles.
Pain — look for non-verbal signs of pain, particularly in people with communication difficulties.
Confirm a diagnosis of delirium by carrying out a cognitive assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or the short Confusion Assessment Method (short-CAM).
The CAM criteria for delirium:
Confusion that has developed suddenly and fluctuates, and
Inattention — ask if the person is easily distracted or has difficulty in focusing attention, and either
Disorganised thinking — ask if the person’s thinking is disorganised, incoherent, illogical, or unpredictable (for example they have an unclear flow of ideas, change subject unpredictably, or have rambling or irrelevant conversation), or
Altered level of consciousness — ask about changes in level of consciousness from alertness to: lethargy (drowsy, easily aroused); stupor (difficult to arouse); comatose (unable to be aroused); or hypervigilant (hyper-alert).
What is the management for delirium?
- treat cause
- manage co-morbidities
- environment –orientate, familiar objects, a clock
- avoid bed moves
- treat underlying cause
- haliperidol as anti-psychotic if needed only if being dangerous, last resort after de-escalation tactics
- mobilise, nutrition, good sleep hygiene
How might hypoactive delirium present?
Sleepy
Less communicative
Reduced oral intake
How might hyperactive delirium present?
Hypervigilant
Paranoia
Psychotic features - hallucinations
Psychomotor agitation
What is more common hyper or hypoactive delirium?
hyper more common
although overall mixed type is more common
What are examples of anti-cholinergic drugs?
ipatropium bromide
antipsychotics
oxybutynin
tricyclic antidepressants
what is the mx of aggressive pts with delirium?
Administering drug treatment is a last resort and should only be done in consultant with senior medical staff. IV treatment should be avoided due to risk of respiratory arrest. The lowest dose of medication and oral route should be opted for.
- first line: lorezepam 0.5 mg PO
- second line: haloperidol
How does delirium tremens present?
Alcohol withdrawal typically presents within the first 24 hours of cessation in patients who have abruptly stopped. Acute alcohol withdrawal may present with tremor, nausea, sweating, seizures, hallucination. Delirium tremens may occur typically 3 days in to cessation with global confusion and sympathetic overdrive (fever, tachycardia and hypertension). This is not the case in this patient.
key confusion screen ix?
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
delirium vs dementia?
delirium:
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions
