Delirium

Question 1

What are the usual presenting features of delirium?

Answer 1

Acute onset
fluctuating course
inattention
disorganised thoughts
altered conscious level

Question 2

Delirium in a patient can have more than one cause. TRUE/FALSE?

Answer 2

TRUE

e.g. direct impact from their medical condition, and issues from their medication

Question 3

What negative consequences does delirium have both for the patient and for the hospital?

Answer 3

• Increased mortality risk
• Prolonged hospital stay (=> complications and cost)
• Long-term disability

Question 4

What complications may patients experience if they have to stay in hospital for a prolonged period due to their delirium?

Answer 4

Hospital acquired pneumonia

Bed “pressure” sores

Question 5

How should the families of delirious patients be reassured?

Answer 5

• Keep them informed of the plans for their relative

- Make them aware that delirium is often caused by precipitants which are treatable

Question 6

What makes Dementia different from delirium?

Answer 6

Dementia

• more insidious onset
• progressive memory loss, not reversible
• Pts often wander and become agitated
• Usually pts with dementia are alert and pay attention

Question 7

How does depression differ from Delirium?

Answer 7

Depression:

• worse in morning
• patients are withdrawn/ apathetic
• low mood
• normal alertness
• relatively normal attention

Question 8

The pathophysiology of delirium is not widely understood. What two theories have been considered as causes?

Answer 8

Direct toxic insults to the brain
e.g. Drugs, hypoxia

Abnormal stress response from the body (metabolic)
e.g. Cortisol, prostaglandins

Question 9

What factors can predispose patients to developing delirium?

Answer 9

• Elderly
• Dementia
• Depression
• Co-morbidities
• Post-operative period
• Sensory impairment
• Polypharmacy
• Alcohol dependency
• Malnutrition

Question 10

What are the main precipitants of delirium?

Answer 10

• Infection
• dehydration
• hypoxia
• medication
• alcohol
• constipation

Question 11

When a patient is described as “disorientated in TPP” what does this mean?

Answer 11

The patient is disorientated in Time, Place, Person

=> cannot recall who or where they are

Question 12

What structures are used during taking a history to assess for delirium?

Answer 12

Confusion Assessment Method (CAM)

4AT (4As Tool)

Question 13

What types of delirium exist and which is most common?

Answer 13

50% HYPOactive
20% HYPERactive
30% mixed

Question 14

Why is HYPOactive delirium more dangerous than hyperactive?

Answer 14

It often goes unnoticed/ undiagnosed as patients are drowsy and aren’t thought to be delirious

Question 15

Describe the difference in symptoms of HYPER and HYPOactive delirium?

Answer 15

HYPER - Agitated, aggressive, wandering

HYPO - Withdrawn, apathetic, sleepy, coma

Question 16

What are the components of the 4AT and what score indicates delirium?

Answer 16

Alertness
AMT4 (name, DOB, place, year)
Attention
Acute change/fluctuation

A score of 4/12 = delirium

Question 17

Describe the CAM process and how delirium is suspected/diagnosed?

Answer 17

Must have both:
1 - Acute onset and fluctuating course
2 - Inattention

AND EITHER OF:
3 - Disorganised thinking
4 - Altered consciousness

Question 18

What environmental changes can be made in hospital setting to help delirious patients feel more comfortable?

Answer 18

• Same staff visiting them
• Quiet/calm environment
• Low night lighting
• Clearly visible clocks and calendars
• Bed as low as possible
• Don’t routinely use bed rails

Question 19

How can the family help to manage patients with delirium?

Answer 19

Keep them informed (leaflets etc)

Allow them to visit when patient is agitated as a familiar face may calm them down

Question 20

What legislation should be considered if the patients do not have capacity to agree to their management?

Answer 20

Mental Health Act
“Adults with Incapacity” section 47

A power of attorney or guardian should be involved in management decisions if possible

Question 21

What is involved in the Think Delirium Time Bundle?

Answer 21

T - Triggers (sepsis, medication, constipation etc)
I - Investigations (assess hydration, bloods, infection)
M - Management
E - Engage and Explain to family (and document delirium diagnosis)

Question 22

Medication can NOT be given to treat delirium. TRUE/FALSE?

Answer 22

FALSE

Medication shouldn’t be given unless a last resort, and the patient is either a harm to themself or others

Question 23

A lady with suspected delirium is admitted on these medications:
aspirin, simvastatin, bendroflumethiazide, co-codamol 30/500, citalopram, levothyroxine and tolterodine.

Which of these could be contributing to her delirium?

Answer 23

Tolterodine = anticholinergic (known to cause delirium)

co-codamol = opiate (can cause delirium)

levothyroxine = are her thyroid function tests okay? if not a metabolic abnormality could cause delirium

Question 24

Patients who experience rehabilitation before an operation are less likely to experience delirium post op. TRUE/FALSE?

Answer 24

TRUE

Question 25

In what conditions should Haloperidol be avoided?

Answer 25

Parkinsons

Lewy Body Dementia

Question 26

When should benzodiazepines be used?

Answer 26

• in alcohol or benzodiazepine withdrawal
• in seizures
• If contraindications to haloperidol

Question 27

Benzodiazepines can worsen delirium. TRUE/FALSE?

Answer 27

TRUE

lorazepam can worsen delirium