Delirium

Question 1

What is delirium?

Answer 1

Disturbance in attention and change in cognition

Question 2

How long does it take for delirium to develop?

Answer 2

Develops over short period of time (hours-days) and tends to fluctuate during the day

Question 3

How common is delirium?

Answer 3

15-60% of older people experience delirium prior to or during hospital admission = diagnosis missed in up to 70%

Question 4

What is the mortality associated with delirium?

Answer 4

10-26% in patients admitted with delirium

22-76% in patients who develop delirium in hospital = high death rate in months following discharge

Question 5

What outcomes is delirium associated with?

Answer 5

Increased mortality, prolonged hospital stay, increased complications, increased cost, long term disability

Question 6

What are the hallmarks of delirium?

Answer 6

Acute change from baseline function
Impaired attention and altered level of consciousness
Fluctuating course

Question 7

What are the types of delirium?

Answer 7

30% have hyperactive delirium
50% have hypoactive delirium
20% have mixed type

Question 8

What type of delirium is associated with worse outcomes?

Answer 8

Hypoactive delirium

Question 9

How do the types of delirium vary from each other?

Answer 9

Hyper = agitated, aggressive, wandering, easy to diagnose
Hypo = withdrawn, apathetic, sleepy/coma, often missed

Question 10

How accurate is the 4AT tool for diagnosing delirium?

Answer 10

89.7% sensitivity and 84.1% specificity

Question 11

What are the categories of the 4AT?

Answer 11

Alertness = scored 0 or 4
AMT4 = scored 0-2
Attention = scored 0-2
Acute/fluctuating course = scored 0 or 4

Question 12

What does the score a patient gets on the 4AT indicate?

Answer 12

Score 1-3 = possible cognitive impairment

Score >= 4 = delirium +/- cognitive impairment

Question 13

What is assessed under the alertness category of the 4AT?

Answer 13

Includes patients who are markedly drowsy or agitated = observe if asleep and attempt to wake, ask patient name and address

Question 14

What do you ask a patient about when carrying out the AMT4 part of the 4AT?

Answer 14

Ask them their age, DOB, location and what the current year is

Question 15

How is a patient’s attention assessed using the 4AT?

Answer 15

Ask the patient to state the months of the years backwards starting from December

Question 16

How is a patient assessed for an acute/fluctuating course of symptoms using the 4AT?

Answer 16

Presence of acute changes or fluctuation in functioning arising over last fortnight and still evident in last 24 hours

Question 17

What is needed to diagnose delirium using the Confusion assessment method?

Answer 17

Diagnosis requires presence of features 1,2 and either 3 or 4

Question 18

What are the features listed under the Confusion assessment method?

Answer 18

1 = acute onset and fluctuating course
2 = inattention
3 = disorganised thinking
4 = altered level of consciousness

Question 19

How should the environment be changed to help manage a patient with delirium?

Answer 19

Quiet and calm, low night lighting, clearly visible clocks and calendars, familiar people, bed as low as possible

Question 20

What is the management of patients with delirium?

Answer 20

Identify and reverse all underlying causes
Try and restore normal sleep pattern
Assess for urinary retention and constipation

Question 21

What investigations are done for delirium?

Answer 21

Start fluid balance chart, ECG, bloods, may do culture if signs of infection

Question 22

What are some general measures that help when managing patients with delirium?

Answer 22

Approach patient calmly and gently from the front
Maintain daytime wakefulness with activities
Allow patients to mobilise as much as possible
Ensure glasses and hearing aids are working

Question 23

What are some common components of delirium prevention programmes?

Answer 23

Anaesthesia protocols, assessment of bladder/bowel functions, early mobilisation, extra nutrition, geriatric consultation, hydration, medication review, pain management, sleep enhancement, therapeutic cognitive activities

Question 24

When can sedation be used on a patient with delirium?

Answer 24

Only when they are a danger to themselves or others = must document reasons for giving sedation

Question 25

What medication may be used to treat delirium?

Answer 25

1st line = haloperidol

2nd line = benzodiazepines

Question 26

What are the benefits of haloperidol?

Answer 26

High potency with few anticholinergic side effects and no active metabolites

Question 27

How is haloperidol prescribed to treat delirium?

Answer 27

Start with low dose = 0.25-0.5mg
Maximum of 5mg can be given in 24 hours
Give orally = avoid IM if at all possible

Question 28

What patients are unsuitable for treatment with haloperidol?

Answer 28

Avoid in Parkinson’s disease and lewy body dementia

Question 29

What patients are treated with benzodiazepines?

Answer 29

Alcohol/benzodiazepine withdrawal or seizures

Haloperidol contraindicated

Question 30

What is the first choice benzodiazepine used to treat delirium?

Answer 30

Lorazepam = shorter acting and fewer active metabolites

May worsen delirium

Question 31

What are some causes of delirium?

Answer 31

Drugs, electrolyte disturbance, drug withdrawal, infection, reduced sensory input, pain, stroke, subdural haemorrhage, urinary incontinence, constipation, metabolic

Question 32

How is delirium screened for?

Answer 32

All patients >65 should be screened for delirium on admission to hospital

Question 33

What is the first line medication for delirium in patients with Parkinson’s disease or lewy body dementia?

Answer 33

Lorazepam 500mcg-1mg oral