Delirium

Question 1

How may a patient with hyperactive delirium present?

Answer 1

Agitated, delusional, hallucinating, wandering, aggressive

Question 2

How may patient with hypoactive delirium present?

Answer 2

Lethargy, slowness with everyday task, excessive sleeping, inattention

Question 3

What are the main causes of delirium?

Answer 3

CHIMPS PHONED:
Constipation
Hypoxia
Infection
Metabolic disturbances (e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration)
Pain
Sleeplessness
Prescriptions (e.g. opiates, benzodiazepines)
Hypothermia/pyrexia
Organ dysfunction (hepatic/renal impairment)
Nutrition
Environmental changes
Drugs (OTC, illicit, recreational, alcohol abuse/withdrawal, smoking)

Question 4

In the Confusion Assessment Method (CAM), what does CAM +ve mean?

Answer 4

Acute onset and fluctuating confusion
AND
Inattention (when counting backwards or reduced attention during review)
AND EITHER
Disorganised thinking (incoherent disorganised speech)
OR
Altered level of consciousness (hyper alert, hypo alert, or both)

Question 5

What is assessed in the 4AT test?

Answer 5

Alertness:
Normal = 0
Abnormal = 4

4AT (age, DOB, current year, current location):
No mistake = 0
1 mistake = 1
2 or more mistake = 2

Attention (months of year backwards):
7 or more correct = 0
less than 7 or doesn’t attempt = 1
Untestable (drowsy/inattentive) = 2

Acute and fluctuating confusion:
No = 0
Yes = 1

Question 6

What investigations should you carry out for a delirious patient?

Answer 6

General Obs:
HR, BP, SaO2, RR, Temp
Fever may suggest sepsis
Tachycardia and hypotension may suggest dehydration or sepsis

CT head:
Ischaemic stroke? intracranial bleeding? SoL?

Bloods:
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatremia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding; high INR = blood coagulates too slowly and high risk of bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
Magnesium (e.g. hypomagnesemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g. hypoglycaemia)
Blood cultures (e.g. sepsis)
CRP

CXR:
Rule out pneumonia

ECG:
Rule out suspected MI

Urine test:
In elderly patients, need +ve dipstick WITH clinical signs and symptoms of UTI

Question 7

When is delirium common in elderly in-patients?

Answer 7

In post-operative periods, following hip fracture/surgery and ICU

After surgery, FBC may be deranged

Question 8

How do you manage delirium?

Answer 8

Treat underlying cause

Modification of the environment

Avoid medication where possible but if needed, NICE recommend Haloperidol (0.5mg orally or 1mg IM) or Olanzapine.
Haloperidol is contraindicated in PD or Lewy body dementia so give lorazepam, quetiapine or clozapine instead.
In alcohol withdrawal, give oral benzodiazepines e.g. chlordiazepoxide

Question 9

What factors favour delirium over dementia?

Answer 9

Delirium can occur in dementia patients

Impairment of consciousness
Fluctuating symptoms: worse at night, periods of normality
Abnormal perception (e.g. illusions and hallucinations)
Agitation and fear
Delusions