Delirium

Question 1

What are the causes of delirium?

Answer 1

• Infection = UTI, chest, skin - wounds, cannulas
• Brain = RICP (bleed, space occupying lesion), stroke, meningitis, alcohol withdrawal
• Resp = CO2 retention, pneumonia, hypoxia
• Cardiac = MI, HR
• Bowel = obstruction, vit B, folate def, dont open bowel 3-4 days - do PR exam
• Iatrogenic = drugs (opiates, anticonvulsants, levodopa, sedatives)
• Liver = failure, uraemia
• Urinary = retention
• Vessels = low Hb, hyponatraemia, hypoglycaemia
• Arthritis = pain
• Sleep = lack off

Question 2

What is delirium?

Answer 2

Any fluctuating baffling behavioural change from the baseline

Question 3

What are the signs and symptoms of delirium?

Answer 3

◦ D = diff in understanding - drowsy, sleepy, lethargic, diff to arose
◦ E = eating/drinking changes
◦ L = language change
◦ I = illusions and hallucinations
◦ R = reversal of sleep/wake cycle
◦ I = inattention
◦ U = unaware of whats going on around them
◦ M = memory impairment (AMTS - assess memory, establish baseline)

Question 4

Outline the different subtypes of delirium

Answer 4

Hypoactive

• psychomotor retardation
• lethargy
• quiet
• paucity of speech

Hyperactive

• oversensitive to stimuli
• psychomotor agitation
• hallucinations
• aggression

Mixed

Question 5

How should delirium be investigated?

Answer 5

• Bloods = FBC, CRP, U+Es, LFTs, glucose, vit B, folate
• Bedside = temp, BM, ECG
• ABG - acid base balance, hypoxia
• CT/MRI head - lesion, RICP (focal neurology can develop later)
• CXR - infection
• AXR - obstruction
• PR - constipation
• Urine dip - infection
• MSU if >65 - infection
• Bladder scan - retention
• LP - meningitis (make sure no RICP first)
• Sepsis screen

Question 6

How should delirium be managed?

Answer 6

• Reduce distress (make sure glasses/hearing aid users have them)
• Nurse in moderately lit room
• Minimise medications
• Treat the cause
◦ Sepsis = 6, IV merpenem
◦ Constipation = laxatives, enema (always query obstruction)
◦ Urinary retention = catheter, TWOC asap
◦ MI
◦T2RF = NIV (must perform CXR before and after - ?pneumothorax)
◦ Infection = Abx

Question 7

What tools can be used to assess and diagnose delirium?

Answer 7

CAM = confusion assessment method (must have 1+2 and either 3 or 4)

• 1: acute, fluctuating
• 2: inattention
• 3: disorganised thinking
• 4: altered level of consciousness

4AT = 4 a’s test (alert, attention, AMT4, acute/fluctuating)

6CIT = Six Item Cognitive Impairment Test

Question 8

Outline how to discriminate between delirium and dementia

Answer 8

Delirium = occurs abruptly, inattention or distraction, usually reversible

Dementia = insidious onset