Delirium Flashcards
How else can delirium be referred to?
Acute confused state (ACS)
What is delirium?
An organic reaction, which can be differentiated from chronic conditions (such as dementia)
What is the progression of delirium?
Patients have a fluctuating, impaired consciousness with an acute onset of hours/days or rapid deterioration of cognitive function
What fraction of patients who suffer from delirium recover completely?
2/3
What is the rue of thirds with regards to delirium recovery?
1/3 recover quickly
1/3 recover slowly - over the course of weeks or months
1/3 never go back to baseline cognition
when is delirium more likely to occur?
When there is already a pre-existing cognitive impairment?
What are the risk factors for delirium?
- Age 65 years
- Male sex
- Pre-existing cognitive impairment e.g. dementia, stroke
- Previous episodes of delirium
- Severe comorbidity
- Operative factors hip fracture repairs and emergency operations are more likely to be associated with delirium
- Certain conditions e.g. AIDs, burns, fracture, infection, low albumin and dehydration
- Current hip fracture or serious illness
- Drug use and dependence e.g. benzodiazepines
- Substance misuse
- Stress
- Social isolation
- Sensory impairment e.g. visual or hearing problems
- Extremes of sensory experience e.g. hypo-/hyperthermia
- Poor mobility
- Movement to new environment e.g. admission to ward
- Electrolyte imbalances
What are the most common causes of delirium?
infection, pre-existing cognitive impairment with exacerbating factor.
What is the DELIRIUM pneumonic for causes of delirium?
Drugs – Benzodiazepines, NSAIDs, Opiates, Antibiotics, TCAs
Eyes and ears – Sensory deprivation
Low O2 - MI, CCF, PE, ARDs, COPD
Infection – UTI, Pneumonia, Cellulitis, Encephalitis
Retention- Urinary or Constipation
Ictal -Post-ictal period post-seizure
Under hydration/Undernutrition
Metabolic – hypercalcaemia, hypoglycaemia
What is the VITAMIN CDE pneumonic for causes of delirium?
Vascular – Cerebrovascular haemorrhage/infarction, cardiac failure or ischaemia, subdural/subarachnoid haemorrhage, vasculitis
Infective – UTI, Pneumonia, Sepsis, etc.
Trauma – Surgery (postoperatively), head injury
Autoimmune/Allergy - SLE
Metabolic – Hypoxia, electrolyte imbalances (hyponatraemia, hypercalcaemia), hypoglycaemia, hyperglycaemia, renal or hepatic impairment.
Idiopathic/Iatrogenic
Neoplasms – primary cerebral malignancies, secondary in the brain, paraneoplastic syndromes
Congenital
Drugs/Degenerative (DRUGS: benzodiazepines, anticonvulsants, steroids, analgesics etc., Toxic substances: alcohol, illicit drugs. DEGENERATIVE:)
Endocrine – hypothyroidism, hyperthyroidism, Cushing’s disease, Carcinoid etc.
What are the three subtypes of delirium?
Hypoactive Subtype drowsy and withdrawn
Hyperactive Subtype agitated and upset, delusions and disorientation
Mixed Subtype Patients vary from hypoactive and hyperactive
What features my be present in delirium?
- Usually acute or subacute presentation
- Fluctuating course
- Consciousness is clouded/impaired cognition/disorientation
- Cognitive function Poor concentration, slow responses. Confusion and disorientation
- Memory deficits – predominantly poor short-term memory
- Abnormalities in the sleep-wake cycle, including sleeping in the day
- Abnormalities of perception e.g. hallucinations or illusions
- Agitation
- Emotional lability
- Psychotic ideas are common however, short duration and simple content
- Neurological signs e.g. unsteady gait or tremor
- Social behaviour lack of cooperation with reasonable requests, alterations in communication
What examinations are required for delirium?
- CVS and respiratory examinations
- Abdominal And genitourinary examinations
- Neuro examinations
- Another indicated examinations e.g. ENT, rectal
What are the DDx for delirium?
- Dementia esp. Lewy Body type as this has a fluctuating course
- Depression
- Bipolar disorder
- Functional psychoses e.g. schizophrenia
What investigations are required for delirium?
- Full history and examination (OFTEN NEED COLLATERAL)
- Bloods FBC, U&Es, Creatinine, glucose, calcium, magnesium, LFTs, TFTs, Cardiac enzymes, vitamin B12, syphilis serology, autoantibody screen, PSA
- Urine dipstick and MSU
- Blood cultures
- ECG
- Pulse oximetry and ABG
- CXR and abdo. X-ray if indicated
- Imaging e.g. CT, MRI
- LP if indicated
- EEG
What is the mainstay of Tx for delirium?
TREAT THE UNDERLYING CAUSE
What environmental measures should be taken for patients with delirium?
- Avoid moving between wards
- Provide a 24hr clock, calendar, appropriate lighting etc. to prevent disorientation
- Address sensory impairment e.g. glasses, hearing aid
- Avoid sensory extremes
- Control excess noise
- Control room temperature
- Adequate nutrition and attention to continence
What supportive management is required for patients with delirium?
- Clear communication
- Reminders of day, time, location and identification of surrounding persons
- Have a clock available
- Familiar objects from home around esp. sensory and mobility aids
- Staff consistency
- Relaxation
- Involve family and carers
What is worrisome when treating delirium with medication?
It can worsen the delirium and cause adverse effects
What treatment may be given to those with delirium secondary to alcohol withdrawal?
Benzodiazepines:
Diazepam
Chlordiazeoxide
What may be given to patient who are aggressive/violent and do not respond to verbal or non-verbal de-escalation techniques?
Antipsychotics - proffered are: Haloperidol and olanzipine
Complications of delirium?
- Hospital-acquired infections
- Pressure sores
- Fractures
- Residual psychiatric and cognitive impairment
- Some progress to stupor, coma and eventual death.
Interventions recommended by NICE to prevent delirium?
o Cognitive impairment or disorientation - provide appropriate lighting and orientate the person, give cognitively stimulating activities, regular visits from familiar people.
o Hypoxia – identify and correct with appropriate amount of oxygen
o Pain – assess verbally and non-verbally and treat
o Medications – review and non-essential medications stopped
o Others – dehydration, constipation, reduced mobility, infection, poor nutrition, sensory impairment and sleep disturbance.
