Delirium

Question 1

What is delirium

Answer 1

Key features:

1. DISTURBED CONSCIOUSNESS = HYPOACTIVE/HYPERACTIVE/MIXED
2. CHANGE in COGNITION = MEMORY, PERCEPTUAL, LANGUAGE, ILLUSIONS, HALLUCINATIONS
3. ACUTE ONSET & FLUCTUANT

Other common features:

• DISTURBANCE of SLEEP-WAKE CYCLE
• DISTURBED PSYCHOMOTOR BEHAVIOUR - delirium affects physical function & mobility
• EMOTIONAL DISTURBANCE

Question 2

Aetiology

Answer 2

NFECTION - not always UTI!!
• DEHYDRATION & BIOCHEMICAL DISTURBANCE
• PAIN
• DRUGS - direct/indirect
• CONSTIPATION/URINARY RETENTION
• HYPOXIA
• ALCOHOL/DRUG WITHDRAWAL - prescription drug withdrawal as well
• SLEEP DISTURBANCE
• BRAIN INJURY - STROKE, TUMOUR, BLEED etc.
• CHANGES in ENVIRONMENT/EMOTIONAL DISTRESS

• Sometimes UNKNOWN + OFTEN MULTIPLE TRIGGERS

Question 3

Investigations/Diagnosis

Answer 3

4AT

Alertness

0 = NORMAL (fully alert, not agitated, throughout assessment)

0 = MILD SLEEPINESS < 10 SECS AFTER WAKING is normal

4 = ABNORMAL

AMT-4 (location, age, DOB, year - current)

0 = NO MISTAKES
1 = 1 MISTAKE
2 = 2 OR MORE MISTAKES/UNTESTABLE

Attention - reverse order of months of the year

0 = ≥ 7 MONTHS CORRECT when listing them backwards

1 = START but SCORES < 7 MONTHS/REFUSES to START

2 = UNTESTABLE (cannot start because unwell, drowsy, inattentive)

Acute change/fluctuating course - alertness, cognition, other mental function starting over last 2 weeks + still present in last 24 hrs

0 = NO
4 = YES

Question 4

Management

Answer 4

○ TREAT CAUSE - FULL Hx + EXAMINATION incl. NEURO + TIME bundle w/I 2hrs

	○ EXPLAIN DIAGNOSIS

	○ BETTER dealt w/ in MDT

Non-pharmacological:

• RE-ORIENTATE & REASSURE AGITATED PT. - use FAMILIES/CARERS
• ENCOURAGE EARLY MOBILITY & SELF-CARE
• CORRECTION of SENSORY IMPAIRMENT - ensure pt. has aids e.g. hearing aids, glasses
• NORMALISE SLEEP-WAKE CYCLE - try to keep awake during day & stimulated
• ENSURE CONTINUITY of CARE - try to ensure same medical staff, don’t move bed/wards
• AVOID URINARY CATHETERISATION/VENFLONS
• DISCHARGE ASAP if in hospital

Pharmacological:

• STOP BAD DRUGS; MOST DRUGS EXACERBATE DELIRIUM
• DRUG Rx usually UNNECCESSARY
• ANTIPSYCHOTICS = DANGER to THEMSELVES/OTHERS or DISTRESS which CANNOT be SETTLED ANY OTHER WAY
  
  • START LOW + GO SLOW - 12.5 mg QUETIAPINE ORALLY
  • CONSULTANT/RESISTRAR DECISION!!

Question 5

Risk factors

Answer 5

• HOSPITALISATION
  
  • POST-SURGERY (up to 50% of pt.)
  • NEAR END of LIFE/OLD AGE (up to 85% of pt.)
  • PREVIOUS EPISODE of DELIRIUM

Question 6

Prognosis

Answer 6

• Generally GETS BETTER
  
  • NOT EVERYONE GETS BACK to PRIOR LVL
  • May UNMASK PREVIOUSLY UNDIAGNOSED COGNITIVE IMPAIRMENT
  • MORE LIKELY to DEVELOP DEMENTIA

MARKER of BAD OUTCOMES

Question 7

Complications

Answer 7

• Massive MORBIDITY + MORTALITY
  
  • INCREASED RISK of DEATH
  • LONGER LENGTH of STAY
  • INCREASED RATES of INSTITUTIONALISATION
  • PERSISTENT FUNCTIONAL DECLINE e.g. falls

Question 8

Capacity

Answer 8

can pt. make decisions about their care - capacity is situation dependent

legally appointed proxy decision maker - welfare POA/guardian