Delirium

Question 1

Definition of Delirium

Answer 1

acute confusional state w/ an acute decrease in cognition from baseline

Question 2

What are the different types of Delirium w/ %s of the prevalence

Answer 2

Hypoactive (40%)
Hyperactive (25%)
Mixed (35%)

Question 3

What is hypoactive delirium

Answer 3

Apathy, withdrawl, lethargy and decreased motor activity

Question 4

What does hypoactive delirium lead to

Answer 4

increased complications, e.g. decreased mobility = increased sores

Question 5

What is hyperactive delirium

Answer 5

increase activity, agitation, hallucinations, challenging behaviours

Question 6

What is mixed delirium

Answer 6

a fluctuating picture, moving between hyper and hypoactive

Question 7

Causes of Delirium

Answer 7

PINCH ME (there are others but this is a good place to start)

Pain
Infection
Nutrition
Constipation
Hydration/Hypoxia

Medication
Environment

Question 8

What are the key characteristics for diagnosis

Answer 8

1. Decreased cognition + attention
2. Acute onset w/ no relation to pre-existing dementia
3. Fluctuation throughout day w/ disturbance to sleep/wake cycle
4. Evidence from history + Exam of a cause related to a medical condition, intoxication or withdrawal
5. AMT <8/10

Question 9

Why do most abnormal behaviours develop on delirium

Answer 9

Due to an abnormal thought

Question 10

How do you investigate a delirium

Answer 10

1. GCS
2. AMT/MOCA/MMSE
3. Confusion Bloods
   FBC
   U+E
   TFT
   LFT
   Glucose
   CRP
   B12
   Folate
   Ca2+
4. Urine dip
5. CXR
6. Consider CT Head/EEG/MRI

Question 11

What is the best way to establish a confusion

Answer 11

Confusion assessment method (CAM)

Question 12

What are the components of the confusion assessment method (CAM) and how is it scored

Answer 12

1. Pt more confused than normal?
2. Innatention?
3. Disorganised Thinking?
4. Altered consciousness level?

1+2 + 3 OR 4 = Delirium

Question 13

What are some predisposing risk factors to delirium

Answer 13

Frailty
Multiple co-morbidities
>65
Sensory impairment
Polypharmacy
Alcohol Excess
Malnutrition
Current Hip fracture

Question 14

What are some precipitating risk factors for delirium

Answer 14

Drug initiation 
Acute Brain Disease
Surgery
Metabolic Abnormality
Infection
Low Sodium 
Hypoxia
Shock
Anaemia
Pain

Question 15

How may Delirium be prevented

Answer 15

1. Identification of high risk patients immediately
2. Keep orientated + promote the familiar
3. Facilitate vision/hearing
4. Keep hydrated/ well fed
5. Keep medications a little as possible
6. Keep mobile and active
7. Promote sleep at night
8. Minimise provocation (noises/tubes/restraints)

Question 16

What drugs should be particularly focused on in delirium

Answer 16

Anticholinergics + Opiates (can contribute to delirium)

Question 17

How do you manage Delirium

Answer 17

1. Identify + Treat underlying cause
2. Manage symptoms (analgesia, hydration etc)
3. Prevent complications
4. Patient and relative Explanations

Question 18

When may sedative drugs be used in delirium

Answer 18

When all other management options have failed

Question 19

What is first-line for RAPID sedation

Answer 19

Lorazepam 0.5mg

Question 20

What is the treatment pathway for non-rapid sedation in delirium

Answer 20

1st line Haloperidol 0.5mg BD

2nd Line Olanzipine

Question 21

What are contraindications for Haloperidol use for sedation

Answer 21

Lewy body dementia or Parkinson’s Disease

Question 22

What role is pharmacological sedation authorised for

Answer 22

1. Rapid tranquilisation of a dangerous patient

2. Short term control of distress (1 drug, lowest possible dose)