Delirium

Question 1

What is delirium

Answer 1

Acute confusional state

Question 2

What are the clinical features of delirium

Answer 2

Globally impaired cognition, perception and consciousness
Develops over hours/days 
Characterized by marked memory deficit 
Disordered or disoriented thinking
Reversal of the sleep wake cycle
Tactile or visual hallucinations

Question 3

List the different types of delirium

Answer 3

Hyperactive
Hypoactive
Mixed

Question 4

Describe hyperactive delirium

Answer 4

Mood lability
Agitation
Aggression
Restlessness

Question 5

Describe hypoactive delirium

Answer 5

Withdrawn

Slow

Question 6

What are the risk factors for delirium

Answer 6

>65
dementia/previous cognitive impairment 
Hip fracture
Acute illness
Psychological agitation (pain)

Question 7

What are some causes of delirium

Answer 7

Surgery/post GA
Systemic infection - pneumonia, UTI, malaria, wounds, IV lines
Intracranial infection or head injury
Drugs/drug withdrawal (opiates, levodopa, sedatives, recreational)
Alcohol withdrawal
Metabolic - uraemia, liver failure, changes in sodium or glucose, decreased Hb, malnutrition
Hypoxia - respiratory or cardiac failure
Vascular - stroke, MI
Nutritional - thiamine, nicotinic acid, B12 deficiency

Question 8

What investigation results would suggest alcohol withdrawal as a cause of delirium

Answer 8

2-5 days post admission, history of alcohol excess

Increased LFTS, MCV

Question 9

List the differentials of delirium

Answer 9

Dementia
Anxiety
Epilepsy
Non-convulsive status epilepticus

Question 10

What investigations should be done when considering delirium

Answer 10

FBC
U&Es
LFT
Blood glucose
ABG
Septic screen (urine dipstick, blood cultures, CXR)
ECG
Malaria screens
LP
EEG
CT

Question 11

Describe the management of delirium

Answer 11

Identify and treat the underlying cause
Reorientate the patient - explain where they are
Encourage visits from family and friends
Monitor fluid balance and encourage oral intake
Be vigilant for constipation
Mobilize and encourage physical activity
Practice sleep hygiene and restrict daytime napping
Avoid and remove catheters, IV cannula, monitoring leads and other devices
Watch for infection and physical discomfort/distress
Review medication and discontinue any unnecessary agents
Only use sedation if the patient is a risk to their own or other patients safety
Consider haloperidol 0.5-2mg or chlorpromazine 50-100mg PO
Wait 20mins to judge effect - further doses can be given if needed

Question 12

Which drugs for delirium should be avoided in elderly and alcohol withdrawal

Answer 12

Chlorpromazine

Question 13

Which drug for deliriums should be avoided in Parkinson’s disease or Lewy body dementia

Answer 13

Antipsychotics

Question 14

How long may delirium persist for?

Answer 14

Beyond the duration of the original illness by several weeks in the elderly

Question 15

When must you reassess to distinguish between delirium persistence and dementia?

Answer 15

1-2months