Delirium

Question 1

What are the hallmarks of delirium?

Answer 1

Acute + fluctuating
Inattention
Altered level of consciousness
Disorganised thinking

Question 2

What are the subtypes of delirium?

Answer 2

Hypoactive
Hyperactive
Mixed

Question 3

How is delirium diagnosed?

Answer 3

Look for hallmarks of delirium

4AT or CAM

Question 4

What are the 4 components of the 4AT?

Answer 4

Alertness
AMT4
Attention
Acute/fluctuating?

Question 5

How is alertness assessed and scored in the 4AT?

Answer 5

Are the drowsy or agitated?
- can ask them to state name/address to help assess

Clearly abnormal = 4
Normal or mildly sleepy for < 10 seconds after waking = 0

Question 6

What is the AMT4 and how is it assessed/scored in the 4AT?

Answer 6

Abbreviated Mental Test 4

• how old are you?
• what is your date of birth?
• where are we?
• what year are we in?

No mistakes = 0
1 mistake = 1
>2 mistakes/untestable = 2

Question 7

How is attention tested/scored in the 4AT?

Answer 7

Tell me the months of the year backwards starting from December

7 or more months = 0
< 7 months or refuses to try = 1
Untestable = 0

Question 8

How is acute/fluctuating scored in the 4AT?

Answer 8

Is this an acute change or fluctuating course?

Yes = 4
No = 0

Question 9

How should the 4AT score be interpreted?

Answer 9

Score of 4 or more = possible delirium

–> follow delirium pathway

Question 10

What is the CAM and how is it assessed?

Answer 10

Confusion Assessment Method:

Diagnose delirium if features 1 + 2 + (3 or 4)

1. acute and fluctuating
2. inattention
3. disorganised thinking
4. altered level of consciousness

Question 11

How should delirium be managed?

Answer 11

Identify and treat precipitant
Call it delirium
Explain to patient/family
Environmental and supportive factors
Consider capacity --> AWI

Question 12

What should you do if using sedation to manage a patient with delirium?

Answer 12

Document WHY it was necessary –> only if danger to self or others
Review the prescription at least every 24 hours to see if still needed
Ensure capacity is documented

Question 13

Which section of the mental health act should be used in a delirious patient if they don’t have capacity?

Answer 13

Adults With Incapacity Act –> Section 47

Question 14

Which drug would be first line for sedation in delirium? Which route + dose?

Answer 14

Haloperidol - oral, avoid IM unless necessary
Start with low dose –> 0.25-0.5mg
Max 5mg in 24 hours

Question 15

Which patients should you avoid giving haloperidol to?

Answer 15

Parkinson’s disease

Lewy body dementia

Question 16

Which sedative drug can be used second line?

Answer 16

Benzodiazepines

Question 17

In which patients would benzos be used instead of haloperidol?

Answer 17

Alcohol or Benzo withdrawal
Seizure
Haloperidol contraindicated

Question 18

Which benzo should be used and why?

Answer 18

Lorazepam –> shorter acting

Benzos can worsen delirium