Delirium

Question 1

What is delirium

Answer 1

Acute confusional state

Question 2

Name some causes

Answer 2

Drugs

Dehydration

Constipation

Withdrawal

Deficiencies

Pain

Electrolyte imbalance

Environmental changes

Hypoxia

Lack of sleep

Long stay

Infection

Infarction

Iatrogenic event

Restricted movement

Organ failure

Injury

Impaired sensory input

Intoxication

Metabolic

Question 3

What does PInCHME stand for and what is it?

Answer 3

Broad causes of delirium

Pain

Infection

Constipation

Hydration

Medication

Environment

Question 4

What are 4 risk factors for delirium

Answer 4

> 65yo

Dementia or prev cog impairment

Hip fracture

Acute illness

Question 5

Clinical features of delirium

Answer 5

globally impaired cognition, perception and consciousness which develops over hours/days

Memory deficit

Disordered/disorientated thinking

Reversal of sleep/wake cycle

Sometimes tactile/visual hallucinations

Question 6

Delirium is split into which categories

Answer 6

Hypo and hyperactive (or mixed)

Question 7

How is hyperactive delirium characterised?

Answer 7

Restless, agitated, aggressive, labile mood

Question 8

How is hypoactive delirium characterised?

Answer 8

Withdrawn, sleepy, quiet

Question 9

What will a delirious person’s mood and affect be like?

Answer 9

Rapidly fluctuating

Question 10

What sort of delusions might someone with delirium have?

Answer 10

Transient delusions that are often persecutory and ideas of reference. May be secondary to abnormal perceptions.

Question 11

Differentials?

Answer 11

Dementia

Anxiety

Non-convulsive status epilepticus

Primary mental illness e.g. schizophrenia

Question 12

How do you distinguish dementia and delirium?

Answer 12

Has there been an ACUTE change from cognitive baseline?

Question 13

How do you distinguish non-convulsive status epilepticus?

Answer 13

EEG

Question 14

How do you assess delirium (investigations etc.) broad categories

Answer 14

Informant history

Mental state assessment

Examine

Investigations

Question 15

What do you need to ask in the informant history

Answer 15

Premorbid level of function

Onset and course of delirium

Drugs and alcohol use/abuse

Question 16

What examinations should you do?

Answer 16

Neuro for FND

Evidence of infection or trauma- cardiac, resp, abdo…

Question 17

What investigations?

Answer 17

Blood- FBC, ESR, U&E, LFT, TFT, Calcium, folate and B12, glucose, ?VDRL for syphilis, ?cultures?

MSU mandatory

CXR

Brain imaging? CT or MRI

Consider EEG if epilepsy a DD

Question 18

Preventative measures for delirium?

Answer 18

Maximise orientation

Prevent causes (e.g. no polypharmacy, good analgesia)

Promote wellbeing e.g. socialising, visits from family and friends, activities to do like puzzles)

Question 19

Management

Answer 19

Treat cause

Reorientate the patient- clocks and calendars, ensure they have their hearing aids and glasses

Try to avoid medication, but if a risk to own/others’ safety then can give typical antipsychotics

Question 20

Would someone with delirium be taken to a psych ward?

Answer 20

No

Question 21

What typical antipsychotics would you give to someone with delirium as a last resort?

Answer 21

Haloperidol 0.5-2mg

Chlorpromazine 50-100mg

PO if they will take it, or IM

Wait 20m to see if works, could give more.

Question 22

When should you NOT give antipsychotics in a delirious patient?

Answer 22

If they have parkinson’s or Lewy Body Dementia

Question 23

Should you ever use physical restraints in delirium?

Answer 23

No

Question 24

Delirium increases the risk of which 4 things

Answer 24

Dementia

Mortality

Length of stay

New admission to long term care

Question 25

Does delirium always resolve when the original illness does?

Answer 25

No, may persist. Don’t assume this is dementia, reassess 1-2m later.