Delirium COPY

Question 1

What is delirium?

Answer 1

Acute confusional state

Question 2

What is the characteristics of delirium?

Answer 2

Acute onset of fluctuating cognitive impairment (worse at night), or deterioration in pre-existing cognitive impairment.

Associated with behavioural abnormalities.

Question 3

What are the clinical features of delirium?

Answer 3

Rapid onset of fluctuating clinical features
Impaired attention
Global impairment of cognition: disorientation, recent memory, abstract thinking
Sleep-wake cycle disturbance - worse at night
Psychomotor agitation
Emotional lability
Visual hallucinations
Thought disorder

Question 4

Outline the epidemiology of delirium

Answer 4

10-20% of medical and surgical inpatients.
Common cause of delayed discharge.
Commoner in chronic cerebral impairment e.g. dementia
Community approx 0.5-1.0%

Question 5

Name 3 at-risk group for delirium

Answer 5

Elderly* or very young
Pre-Existing dementia
Blind or deaf
Post-op (especially cardiac)
Alcohol- and benzodiazepine-dependent
Serious and/or multiple illnesses

Question 6

List the 3 common clinical presentations of delirium

Answer 6

Hyperactive/agitated delirium
Hypoactive delirium
Mixed delirium

Question 7

Describe hyperactive delirium

Answer 7

Psychomotor agitation
Increased arousal
Inappropriate behaviour
Delusions - commonly persecutory
Hallucinations - commonly visual

Question 8

Describe hypoactive delirium

Answer 8

Psychomotor retardation
Lethargy
Excess somnolence (drowsiness)

Question 9

Describe mixed delirium

Answer 9

Combination of hyperactive and hypoactive delirium with varying presentation over time

Question 10

Name 3 infective causes of delirium

Answer 10

UTI
Chest infection
Wound abscess
Cellulitis
Subacute bacterial endocarditis

Question 11

Name 3 metabolic causes of delirium

Answer 11

Anaemia
Electrolyte disturbance
Hepatic encephalopathy
Uraemia
Hypothermia

Question 12

Name 3 intracranial causes of delirium

Answer 12

Stroke
Head injury
Encephalitis
Malignancy
Raised ICP

Question 13

Name 3 endocrine causes of delirium

Answer 13

Hypoglycaemia
Diabetes mellitus
Pituitary disease
Thyroid disease
Parathyroid disease
Adrenal disease

Question 14

Name 3 substance-related causes of delirium

Answer 14

Alcohol
Psychotropics: Antidepressants, antipsychotics, benzodiazepines
Opiates
Diuretics
Lithium
Antiparkinsonian drugs
Anticholinergic drugs

All drugs can cause delirium

Question 15

Describe the illness course of delirium

Answer 15

Sudden onset
Fluctuating course
Gradual resolution with effective treatment of underlying cause

Question 16

How does illness course differ for elderly patients with delirium?

Answer 16

Symptom resolution may be much slower

Question 17

Outline the prognosis of delirium

Answer 17

Increased duration of stay and increased complications
High mortality (20% during admission, up to 50% at 1yr)
Institutionalisation by 1 yr (45%)
Readmission within 1 yr (20%)

Question 18

What is the association between delirium and dementia?

Answer 18

Delirium causes neuronal death ➔ independent cause for dementia development and progression

Question 19

What investigations can be used to assess delirium?

Answer 19

Bedside cognitive testing: orientation, MMSE, Addenbrooke’s

EEG

Question 20

What EEG finding would be present in delirium?

Answer 20

Generalised slowing

Theta, delta, and alpha reduction

Question 21

Outline the management principles for delirium

Answer 21

Identify and treat underlying causes
Environmental and supportive measures
Avoid sedation unless severely agitated or a risk
Regular clinical review and follow-up

Question 22

Name 4 environmental and supportive measures in the management of delirium

Answer 22

Maintain hydration and nutrition
Physical environment
Human environment
Control of distressing physical symptoms
Avoid unnecessary procedures
Promote healthy sleep patterns

Question 23

Name 3 physical environmental factors for optimal management of delirium

Answer 23

Safe environment
Adequate lighting
Noise reduction
Clocks and calendars
If appropriate, hearing and visual aids

Question 24

Name 2 human environmental factors for optimal management of delirium

Answer 24

Same group of staff
Firm clear communication
Routine
Prevent transfer
Education for those interacting with patient

Question 25

What medication is avoided for delirium management?

Answer 25

Do not use:
Long acting drugs
Tranquillisers with multiple side effects - esp cardiovascular and anticholinergic side effects

Question 26

What initial drug is used to manage the majority of delirium?

Answer 26

Low dose haloperidol (0.5-1.0mg BD)

Treat with antipsychotics
Minimum possible dose for shortest period of time

Question 27

When are benzodiazepines appropriate for delirium?

Answer 27

Alcohol withdrawal delirium

GBL withdrawal delirium

Question 28

Differentiate dementia from delirium

Answer 28

Delirium has altered consciousness and attention.

Dementia: Gradual onset, duration months to years, progressive deterioration, normal consciousness, perceptional disturbances occur later, normal sleep-wake cycle.

Delirium: Acute onset, duration hours to weeks, fluctuating course, impaired consciousness, perceptional disturbances are common, disrupted sleep-wake cycle.