Delirium

Question 1

name 7 causes of delirium

Answer 1

infection
medications
change in environment
surgery
dehydration
constipation
pain

Question 2

risks after delirium?

Answer 2

35-40% death risk in the following year

prolonged hospital stay and associated complications (infection, bed sores etc)

Question 3

what are the defining aspects of delirium?

Answer 3

disturbance in attention
acute change in cognition (hours-days)
fluctuates during the day
evidence that this change is a direct physiological consequence

Question 4

9 features of delirium?

Answer 4

sudden onset
short, fluctuating course
lasts hours - less than a month
agitated/restless or sleepy/slow (can be mixed)
alertness fluctuates
impaired attention
fluctuating emotions
disorganised thinking
distorted perception

Question 5

9 features of dementia?

Answer 5

slow insidious onset
progressive, not reversible
wandering, agitated activity
generally normal alertness
normal attention
low mood may be present
word-finding difficulties
normal perception (in early stages)

Question 6

describe the pathophysiology of delirium?

Answer 6

can be a direct toxic insult on the brain (drugs, hypoxia, low sodium/glucose etc)
variable derangement of neurotransmitters (ACh)
unusual stress responses can contribute (cortisol, prostaglandins, cytokines etc)

Question 7

precipitants vs predisposing factors in delirium?

Answer 7

precipitants = direct cause (e.g infection)

predisposing factors = age, underlying disease (dementia etc)

Question 8

name 9 predisposing factors for delirium?

Answer 8

age
dementia
illness
post surgery
sensory impairment (hearing/sight)
polypharmacy
depression
alcohol dependency 
malnutrition

Question 9

medications associated with delirium?

Answer 9

opiates
anticholinergics
sedatives

Question 10

precipitants for delirium?

Answer 10

hypoxia
dehydration
urine infections
biochemical abnormalities (sugar/salt)
alcohol excess
dehydration
HAP
catheters
systemic upset
cardiovascular disease (MI, ACS)
fractures (esp neck of femur)
constipation
urinary rertention

Question 11

how is delirium diagnosed?

Answer 11

clinical diagnosis - recognise hallmarks

• acute and fluctuating
• inattention
• altered consciousness
• disorganised thinking

Question 12

what are the 3 subtypes of delirium?

Answer 12

hyperactive (20%)
hypoactive (50%)
mixed (30%)

Question 13

which subtypes of delirium has the highest mortality?

Answer 13

hypoactive

- often go under the radar

Question 14

what is the 4AT?

Answer 14

tool for diagnosing delirium
4As
- alertness
- AMT4
- attention
- acute change

Question 15

what is CAM?

Answer 15

confusion assessment method
4 features
- acute and fluctuating
- inattention
- disorganised thinking
- altered consciousness
must have 1,2 and either 3 or 4

Question 16

how is delirium managed?

Answer 16

identify delirium
reverse underlying causes
environmental and supportive factors
communication and reassurance with relatives/carers
control symptoms
clinical review and follow up
consider capacity

Question 17

TIME bundle?

Answer 17

strategy for delirium
T- think delirium, treat possible triggers
I - investigate and intervene
M - management plan
E - explain, engage and explore causes

Question 18

what measures can be taken prior to surgery to prevent delirium in the elderly?

Answer 18

manage medications, nutrition, hydration, environment etc

Question 19

how are pharmacological measures used in delirium?

Answer 19

very rarely
sedation only used if patient is a danger to themselves or others
- haloperidol
- benzodiazepines (used in alcohol/diazepam withdrawal or if haloperidol contraindicated)

Question 20

how are dementia and delirium linked?

Answer 20

delirium is risk factor for dementia

people with dementia more likely to get delirium