Delirium

Question 1

What is delirium?

Answer 1

An acute confusional state characterized by impaired attention, disorientation, memory changes and perceptual disturbances

Is acute onset (hours-weeks)
- cognitive impairment is always present

May present with emotional or behavioral disturbances

Question 2

When to ask/screen for delirium

Answer 2

When hospitalized patient is acting different from their baseline readings

When a medically complex outpatient is presenting with new onset of confusion, depression or dysregulation
- this is often geriatric patients

Question 3

DSM-5 criteria for delirium

Answer 3

A disturbance in attention and awareness that develops over a short period of time (Horus- few days) and represents a change from baseline attention/awareness
- often fluctuates throughout the day

May also present with cognition disturbances

are not better explained about a neurocognitive disorder (dementia/coma)

• *MUST be evidence that this disturbance is a direct physiological consequence of one of the following
• medical conditions
• substance intoxication or withdrawal
• exposure to a toxin**

Question 4

Specifics and type of delirium

Answer 4

1) Acute vs persistent
2) Hypoactive/hyperactive/mixed

3) Causes:
- substance intoxication/withdrawal
- medication-induced
- secondary to medical cause
- secondary to multiple etiologies

Question 5

How to screen for delirium

Answer 5

Can you tell me the full date and where we are right now?

Have you seen anything unusual in the room?

Can you spell the word “world”? Can you spell it backwards?

Ask serial 7’s

Naming months or days of the weeks backwards

Question 6

Delirium epidemiology

Answer 6

15-21% in geriatric patients admitted to medicine

10-15% of surgical patients

30% of all open heart surgeries

50% of patients who experience hip fractures

70-87% of all ICU patients

83% of patients receiving EOC care

Question 7

Risk factors

Answer 7

Age > 65

Male

History of cognitive impairment
- often dementia

Depression

Immobility

Functional dependence

Sensory impairments

Dehydration/malnutrition

Underlying medical conditions

Question 8

Delirium pathophysiology

Answer 8

ACh seems to be involved although to what extent is unknown

Major brain areas involved are

• reticular formation
• brainstem

Major pathway = dorsal tegmental pathway

EEG shows diffuse background slowing

Question 9

Differential diagnosis of delirium

Answer 9

Dementia*

• longer/chronic onset (vs acute for delirium)
• sundowning is present (NOT present in delirium)

Seizures

Catatonia*

Mood/ psychiatric disorders

CNS lesions

• Anton syndrome
• tumors

Question 10

Delirium prognosis

Answer 10

Kinda high actually

• 14% at 1 month
• 22% at 6 months

Question 11

Treatment of delirium

Answer 11

Always try to treat underlying reason for delirium if present

• infections
• CNS processes
• wernickes encephalitis
• metabolic derangement
• organ failures
• trauma/pain
• burns
• medications

Next step is orientation protocols (trying to help the patient get more orientated such as keeping a clock or calendar)

Next step is meds to treat delirium itself

Absolute last resort is restraints

Question 12

What medications can cause delirium

Answer 12

Opiods

Benzos

Anticholinergic

Dopamine agonists

Antifungal

Antiarrhythmics

Question 13

Why is thiamine supplements often given in delirium?

Answer 13

Incase a patient has wernickes encephalopathy
- is a common cause of delirium and is easily reversible unless it becomes korsakoffs

mamillary atrophy = Korsakoff’s syndrome

Question 14

Meds to treat delirium

Answer 14

Haldol w/ diphenhydramine or other antipsychotics*

- limited evidence so is not first line but if secondary reasons are ruled out its okay