Delirium

Question 1

Define delirium

Answer 1

Acute change in mental state

Fluctuant

Question 2

Features of delirium

Answer 2

Disturbed consciousness - hypoactive, hyperactive, mixed

Change in congnition - memory, perceptual,language, illusions, hallucinations

Question 3

Consequences

Answer 3

Disturbance in sleep/wake cycle
Disturbed psychomotor behaviour –> falls
Emotional disturbance - misdiagnosed as depression, anxiety- key difference in onset

Question 4

Risk increases with,,

Answer 4

cognitive and physical frailty

Question 5

Possible cause of delirium

Answer 5

maladaptive inflammatory response

Question 6

Causes in healthy patients

Answer 6

Tumours/Strokes/Sepsis

Question 7

Elderly/frail causes

Answer 7

Wil be precipitated by smaller events than serious illness

Use cognitive frailty to gauge severity of insults

Question 8

What precipitates delirium?

Answer 8

Infection
Dehydration
Pain
Drugs- sedatives, anticholinergics
Constipation, urinary retention
Hypoxia
Alcohol/drug withdrawal
Sleep disturbance
Brain injury- stroke/tumour/bleed
Changes in environment- emotional distress

Question 9

Stats of inpatients, postsurgery, lifetime occurrences

Answer 9

20-30% inpatients
50% postsurgery
85% lifetime

Question 10

Markers of severe illness - poorer outcomes

Answer 10

Morbidity, mortality
Functional decline
Dementia
longer length of stay
Institutionalisation

Question 11

Diagnosis of delirium

Answer 11

4AT Screening
AMT4 - Location, Age, DOB, Year (All correct- score = 0)

Ask relatives and friends for history

Question 12

Treatment/Management of delirium

Answer 12

TIME
Triggers
Investigate - Bloods, CT
Management plan
Engage, explore, explain to patient

Question 13

Non-pharmalogical treatment of delirium

Answer 13

Reorientate, reassure - use families/carers
Encourage early mobility and self care
Correct sensory impairment
Normalise sleep/wake cycle
Continuity of care

Avoid catheterisation/ venflons
Discharge ASAP

Question 14

Pharmacological Rx of Delirium

Answer 14

Avoid - antipsychotics increase morbidity/mortality

Oral quetiapine 12.5mg before escalation

Question 15

Prevention of delirium

Answer 15

Orientation- ensure glasses and hearing aids to hand
Promote sleep hygiene
Early mobilisation
Pain control
Prevent/early identification and Rx of postop complications
Regulate bowel and bladder fxn
Provision of supplementary oxygen
Medication review by experienced HCP

Question 16

Trajectory of delirium

Answer 16

Will settle quickly when underlying cause managed
Patient may not return to previous state
May unmask undiagnosed cognitive impairment
More likely to develop dementia
Risk of further episodes- follow-up needed

Question 17

Assess capacity

Answer 17

Legally appointed proxy decision maker may be needed

Question 18

Likelihood of falls associated with delirium

Answer 18

4.5 x more likely

Question 19

Associated with overdiagnosis of…?

Answer 19

UTI
Asymptomatic bacteruria in elderly (women >75)
Dipstick not diagnostic
Prescribed unnecessary antibiotics

Question 20

Case
‘poor historian, confused, smells of urine’
Obs – HR 100, BP 100/60, T 36.4
Looks dry, GCS 14/15, no focal neurology, abdo soft, tender lower abdomen

Urea 22, Cr 220, CRP 200, Ca 2.7
CXR – right basla consolidation
Bladder scan – 700ml

Answer 20

Medication
Zopiclone 7.5mg at night (sleeping)
Furosemide 80mg (dry - stop)
Amitriptyline 10mg night (tricyclic antidepressant)
Ramipril 10mg 
Bisoprolol 2.5mg
Paracetamol 1g as required
Tamsulosin 400mcg (BPH alpha bocker, lowers BP)

No drip
Manage urinary retention with enema (catheterise if pain)
Pneumonia - manage by guidelines - coamoxiclav for c diff risk, escalate if any changes
MDT - Geriatrics need to assess