Delirium

Question 1

What are the hallmarks of delirium?

Answer 1

Acute and fluctuating
Inattention
Altered level of consciousness
Disorganised thinking

Question 2

What are the negative long term consequences of delirium?

Answer 2

Increased mortality 
Prolonged hospital stay
Increased complications; FVT, HAP, pressure sores 
Increased cost 
Long-term disability

Question 3

Describe dementia: 
Onset
Course
Duration 
Activity
Alertness
Attention 
Mood
Thinking
Perception

Answer 3

Onset: slow and insidious
course: progressive, irreversible
Duration: months to years
Activity: wandering, agitated
Alertness: normal
Attention: normal 
Mood: low mood may be present
Thinking: word-finding difficulties 
Perception: usually normal in early stages except lewy body dementia

Question 4

Describe depression: 
Onset
Course
Duration 
Activity
Alertness
Attention 
Mood
Thinking
Perception

Answer 4

Onset: abrupt with life changes
Course: worse morning 
Duration: at least 2 weeks
Activity: withdrawn, apathy
Alertness: normal
Attention: normal 
Mood: depressed
Thinking: slow, depressive themes
Perception: intact but delusions and auditory hallucinations in severe cases

Question 5

Describe delirium:
Onset
Course
Duration 
Activity
Alertness
Attention 
Mood
Thinking
Perception

Answer 5

Onset: sudden; hours, days
Course: short, fluctuating, reversible
Duration: hours to less than a month
Activity: agitation, restless (hyperactive) or sleepy and slow in hypoactive
Alertness: fluctuates
Attention: impaired, difficult to converse
Mood: fluctuating emotions
Thinking: disorganised
Perception: distorted; illusions and visual hallucinations, delusions

Question 6

What is the pathophysiology of delirium?

Answer 6

Direct toxic insult to brain: drugs, hypoxia, stroke, hypoglycaemia, dehydration
Abnormalities within body normal stress pattern

Question 7

What are precipitating factors for developing delirium?

Answer 7

Hypoxia
Biochem abnormalities
Dehydration 
Alcohol excess
HAP
UTI
Environmental 
Catheters 
Systemic upset - intercurrent illness
CV disease 
#NOF 
Constipation 
Urinary retention 
Pre-existing dementia

Question 8

Which drugs are particularly bad for precipitating delirium?

Answer 8

Sedative hypnotics - haloperidol, lorazepam Narcotics - esp opioids Anticholinergic drugs Corticosteroids Polypharmacy
Withdrawal of alcohol

Question 9

What are the subtypes of delirium?

Answer 9

Hyperactive: agitated, aggressive, wandering
Hypoactive: withdrawn, apathetic, sleepy, coma

Question 10

What 4 A’s does the 4AT scoring system use?

Answer 10

Alertness: difficult to rouse, hyperactive
AMT4
Attention: please tell me the month of the year in backwards order starting at december
Acute change or fluctuating course: evidence of significant change or fluctuation in alertness, cognition or other mental function (paranoia, hallucinations) arising over the last 2 weeks and still evident in the last 24 hours

Question 11

What is AMT4?

Answer 11

Age
D.O.B
Place (hospital)
Current year

Question 12

What score on 4AT indicates delirium?

Answer 12

4 or above

Question 13

What is the CAM method?

Answer 13

Confusion assessment method

Question 14

What is required in CAM to diagnose delirium?

Answer 14

Feature 1,2 and either 3 or 4

1: acute onset and fluctuating course
2: inattention
3: disorganised thinking
4: altered level of counsciousness

Question 15

What acute and severe causes of delirium must be ruled out?

Answer 15

Infection/sepsis
Hypoxia
Hypoglycemia
Medicine intoxication

Question 16

What should be in place if the patient lacks capacity with no power of attorney?

Answer 16

AWI section 47

Question 17

What is the TIME framework for delirium?

Answer 17

Think
Investigate
Management
Engage and explore

Question 18

What is included in the T of TIME?

Answer 18

Think, exclude and treat possible triggers:
NEWs (sepsis 6)
BG
Med history (any new meds/change of dose/any stopped)
Assess for urinary retention
Assess for constipation

Question 19

What is included in the I of TIME?

Answer 19

Investigate and intervene to correct any underlying causes:
Assess hydration and start fluid balance chart
Bloods (FBC, U&Es, LFT, CRP, Mg)
Infection (skin, chest, urine, CNS) and perform appropriate cultures/imaging
ECG (MI/ACS)

Question 20

What is included in M of TIME?

Answer 20

Management plan

Question 21

What is included in E of TIME?

Answer 21

Engage with patient, family and carers
Explain diagnosis
Document diagnosis of delirium

Question 22

What medication can be given in delirium?

Answer 22

LAST RESORT
Haloperidol 0.5-1.0mg PO or 0.5mg IV
AVOID IN PARKINSON’S OR LEWY BODY DEMENTIA
Lorazepam 0.5-1.0mg PO BUT benzodiazepines can worsen or prolong delirium

Question 23

What environmental changes can be made to aid with delirium recovery?

Answer 23

Ensure glasses and hearing aids available 
Provide regular reassurance and orientation 
Use family/familiar faces 
Reduce noise and visual overstimulation 
Consider additional staff
Sleep chart 
Regular mobilisation 
Reduce stress
Adequate nutrition and fluids 
Avoid bed moves

Question 24

What are some common successful delirium prevention programmes?

Answer 24

Anaesthesia protocols
Assessment of bowel/bladder function 
Early mobilization 
Extra nutrition 
Geriatric consultation 
Hydration 
Med review 
Pain management 
Sleep enhancement
Supplemental O2 if hypoxic

Question 25

Why should delirium be followed up in a clinic?

Answer 25

Flashbacks can be distressing

An episode of delirium is a risk factor for developing dementia

Question 26

What should be done if a patient has delirium?

Answer 26

Check bloods; electrolytes and glucose
Ensure good hydration 
Septic screen
Hypoxia
ECG for MI/ arrhythmia
Stop drugs with neurotoxic effects
Relieve pain but beware too much opioid
Avoid urinary catheter unless retention 
Treat constipation 
Think about alcohol withdrawal