Delirium Flashcards
Psychiatric differential for acute behavioural disturbance
Delirium
Dementia (esp Lewy body)
Schizophrenia
Drug-induced psychosis
Delirium trements (alcohol withdrawal)
Onset in delirium vs dementia
Acute in delirium, insidious in dementia
Short-term course in delirium vs dementia
Fluctuating in delirium, constant/progressive decline in dementia
Attention in delirium vs dementia
Poor attention in delirium, relatively spared in dementia (clear consciousness, not drowsy)
Delusions and hallucinations in delirium vs dementia
More common, simple, and fleeting in delirium
Clinical features of delirium
Attention + awareness of surroundings impaired
Behaviour: Irritable/agitated, or somnolence + reduced activity
Consciousness: clouded, impaired concentration, disorientation in time + place
Delusions: Transient persecutory +/- visual hallucinations
Fluctuating, often worse at night
Simple screening tools for delirium
Months of the year backwards
AMTS
Questions in the AMTS
- Age
- DOB
- Recall 42 West street
- Time
- Current year
- Place
- Person
- Current monarch
- Year of WW2
- Count backwards 20 to 1
% of delirium where drugs implicated
1/3 of cases
Differential for confusion/memory loss
Deafness/dysphasia
Dementia
Delirium
Post-ictal state (epilepsy, complex partial seizure)
Drugs (esp anticholinergics)
Predisposing factors for delirium
- Demographic: Elderly, male
- Neurological Hx: Dementia, sensory impairment
- PMHx: Frailty/immobility, Hx of delirium
Psychiatric drugs commonly causing delirium
Tricyclic antidepressants
Lithium
Benzodiazepines, sedatives (paradoxical agitation in young males)
Benzodiazepine withdrawal
Cardiac drugs commonly causing delirium
Diuretics
Digoxin
Other drugs commonly causing delirium
Alcohol + alcohol withdrawal
Opiates
Steroids
Neurological conditions causing delirium
Epilepsy (post-ictal)
Space-occupying lesion (e.g. tumour, haematoma)
Head injury
Encephalitis, abscess
Medical conditions causing delirium
Systemic: sepsis, dehydration, constipation
Trauma: Post-op, burns, hypoxia, poor pain control
Endocrine: Hyperthyroidism, Addisonian crisis, deranged PTH
Autoimmune: SLE
Metabolic: Liver/renal failure, deranged U&Es, hypoglycaemia (esp if diabetic)
Environmental components in management of delirium
Quiet room with clock and good lighting
Few, named staff
Regular routine
Capacity assessment
Investigations for delirium
- Bloods: FBC, U&E, LFT, glucose, cultures
- O: MSU + culture
- X: CXR
- ECG
- Polypharmacy drug review
Medical managment of delirium
- Assess nutrition, hydration, O2 sats
- Assess mobility, bowel habits, urinary frequency
- Infection screen
- Review medication
- Pharmacological intervention if necessary
Pharmacological options for delirium
Lorazepam (or other benzo) as first-line (0.5-1mg) if acutely disturbed
Olanzapine/haloperidol if necessary, but not within 1h
Hypnotic for sleep disturbance
Check local trust guidelines
2-4 year mortality followng delirium in >65
55%
Indications for antipsychotics in delirium
Risk to self/others
Distress from hallucinations
Indication benzodiazepine in delirium
Acute behavioural disturbance/agitated patient
Onset of lorazepam
15-30 min
Max dose lorazepam per 24h
4mg
Typical lorazepam doses
0.5-1mg 4-hourly for PRN
1-2mg for sedation
Alternative to IM lorazepam if compromised respiratory function/sensitivity or tolerance to BDZs
50mg promethiazine IM
Physical observations following tranquilization
Every 15 mins for 1 hr
Every hour for 4 hours
4-hourly for 24 hours
Watch out for respiratory depression
Antidote for benzodiazepines
Flumazenil
