Delirium COPY Flashcards
What is delirium?
Acute confusional state
What is the characteristics of delirium?
Acute onset of fluctuating cognitive impairment (worse at night), or deterioration in pre-existing cognitive impairment.
Associated with behavioural abnormalities.
What are the clinical features of delirium?
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
Outline the epidemiology of delirium
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%
Name 3 at-risk group for delirium
Elderly* or very young Pre-Existing dementia Blind or deaf Post-op (especially cardiac) Alcohol- and benzodiazepine-dependent Serious and/or multiple illnesses
List the 3 common clinical presentations of delirium
Hyperactive/agitated delirium
Hypoactive delirium
Mixed delirium
Describe hyperactive delirium
Psychomotor agitation Increased arousal Inappropriate behaviour Delusions - commonly persecutory Hallucinations - commonly visual
Describe hypoactive delirium
Psychomotor retardation
Lethargy
Excess somnolence (drowsiness)
Describe mixed delirium
Combination of hyperactive and hypoactive delirium with varying presentation over time
Name 3 infective causes of delirium
UTI Chest infection Wound abscess Cellulitis Subacute bacterial endocarditis
Name 3 metabolic causes of delirium
Anaemia Electrolyte disturbance Hepatic encephalopathy Uraemia Hypothermia
Name 3 intracranial causes of delirium
Stroke Head injury Encephalitis Malignancy Raised ICP
Name 3 endocrine causes of delirium
Hypoglycaemia Diabetes mellitus Pituitary disease Thyroid disease Parathyroid disease Adrenal disease
Name 3 substance-related causes of delirium
Alcohol Psychotropics: Antidepressants, antipsychotics, benzodiazepines Opiates Diuretics Lithium Antiparkinsonian drugs Anticholinergic drugs
All drugs can cause delirium
Describe the illness course of delirium
Sudden onset
Fluctuating course
Gradual resolution with effective treatment of underlying cause
How does illness course differ for elderly patients with delirium?
Symptom resolution may be much slower
Outline the prognosis of delirium
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%)
What is the association between delirium and dementia?
Delirium causes neuronal death ➔ independent cause for dementia development and progression
What investigations can be used to assess delirium?
Bedside cognitive testing: orientation, MMSE, Addenbrooke’s
EEG
What EEG finding would be present in delirium?
Generalised slowing
Theta, delta, and alpha reduction
Outline the management principles for delirium
Identify and treat underlying causes
Environmental and supportive measures
Avoid sedation unless severely agitated or a risk
Regular clinical review and follow-up
Name 4 environmental and supportive measures in the management of delirium
Maintain hydration and nutrition Physical environment Human environment Control of distressing physical symptoms Avoid unnecessary procedures Promote healthy sleep patterns
Name 3 physical environmental factors for optimal management of delirium
Safe environment Adequate lighting Noise reduction Clocks and calendars If appropriate, hearing and visual aids
Name 2 human environmental factors for optimal management of delirium
Same group of staff Firm clear communication Routine Prevent transfer Education for those interacting with patient
What medication is avoided for delirium management?
Do not use:
Long acting drugs
Tranquillisers with multiple side effects - esp cardiovascular and anticholinergic side effects
What initial drug is used to manage the majority of delirium?
Low dose haloperidol (0.5-1.0mg BD)
Treat with antipsychotics
Minimum possible dose for shortest period of time
When are benzodiazepines appropriate for delirium?
Alcohol withdrawal delirium
GBL withdrawal delirium
Differentiate dementia from delirium
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.
