Delirium + Dementia

Question 2

Causes of delirium

Answer 2

PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication/Metabolism
Environment/Electrolytes

Question 3

Treatment for delirium

Answer 3

Recovery can take 3-6 months!

Treatment
Treat the cause
Supportive environment
May need benzodiazepines or antipsychotics

Question 4

Treatment for delirium

Answer 4

Recovery can take 3-6 months!

Treatment
Treat the cause
Supportive environment
May need benzodiazepines or antipsychotics

Question 5

Features of Hypoactive (40%) delirium

Answer 5

Lethargy, dec motor activity, apathy and sleepiness
Most common type of delirium but often unrecognised
Can be confused with depression

Question 6

Features of hyperactive (25%) delirium

Answer 6

Agitation, irritability, restlessness and aggression
Hallucinations and delusions prominent
Maybe confused with functional psychoses

Question 7

Mixed (35%) delirium features

Answer 7

Both hypo- and hyperactive subtypes co-exist and therefore there are signs of both

Question 8

Causes of delirium

Answer 8

HE IS NOT MAAD
Hypoxia - resp failure, MI, HF, PE
Endocrine - Hyper+Hypo T, hyper + hypoglycaemia, cushings
Infection - UTI, Pneumonia, encephalitis, meningitis
Stroke - Stroke, raised ICP, intercranial haemorrhage, space occupying lesions
Nutritional- Dec thiamine, nicotinic acid, vitamin B12
Others - pain, sensory deprivation, sleep deprivation
Theatre - Anaesthetic, opiate analgesics
Metabolic - Hypoxia, hyponatraemia, hep + renal impairment
Abdominal - faecal impaction, malnutrition, urinary retention
Alcohol
Drugs - benzos, opioids, anti-Parkinsonism, steroids

Question 9

Most common cause of delirium

Answer 9

UTI

Question 10

Epidemiology of delirium

Answer 10

Delirium occurs in about 15–20% of all
general admissions to hospital.
Delirium is the most common complication of hospitalization in the elderly population.
Up to two-thirds of delirium cases occur in inpatients with pre-existing dementia.
15% of >65s are delirious on admission to hospital.

Question 11

RFs for delirium

Answer 11

Older age ≥65
Multiple co-morbidities
Dementia
Physical frailty
Renal impairment
Male sex
Sensory impairment
Previous episodes
Recent surgery
Severe illness (e.g. CCF)

Question 12

Clinical features of Delirium

Answer 12

DELIRIUM
Disordered thinking: Slowed, irrational, incoherent thoughts.
Euphoric, fearful, depressed or angry.
Language impaired: Rambling speech, repetitive and disruptive.
Illusions, delusions (transient persecutory or delusions of misidentification) and
hallucinations (usually tactile or visual).
Reversal of sleep-wake pattern: i.e. may be tired during day and hyper-vigilant at night.
Inattention: Inability to focus, clouding of consciousness.
Unaware/disoriented: Disoriented to time, place or person.
Memory deficits.

Question 13

ICD-10 criteria for the diagnosis of delirium

Answer 13

• Impairment of consciousness and attention
• Global disturbance in cognition
• Psychomotor disturbance
• Disturbance of sleep-wake cycle
• Emotional disturbances.

Question 14

Delirium Key facts

Answer 14

Sleep-wake cycle Disrupted
Attention Markedly reduced
Arousal Increased/decreased
Autonomic features Abnormal
Duration Hours to weeks
Delusions Fleeting
Course Fluctuating
Consciousness level Impaired
Hallucinations Common (especially visual)
Onset Acute/subacute
Psychomotor activity Usually abnormal

Question 15

Dementia key facts

Answer 15

Sleep-wake cycle Usually normal
AttentionNormal/reduced
Arousal Usually normal
Autonomic featuresl Normal
Duration Months to years
Delusions Complex
Course Stable/slowly progressive
Consciousness level No impairment
Hallucinations Less common
Onset Chronic
Psychomotor activity Usually normal

Question 16

Historical questions to ask in delirium

Answer 16

Much of the history may be collateral as obtaining the history from the patient may
prove very difficult.
Identify rate of onset and course of the confusion.
Any symptoms of underlying cause, e.g. symptoms of infection or of intracranial
pathology?
Having an understanding of their premorbid mental state is important.
Are they hypo-alert or hyper-alert?
Do they have hypersensitivity to sound and light?
Is there any perceptual disturbance (misidentification, illusions and
hallucinations)?
Take a thorough drug history and a full alcohol history

Question 17

MSE for delirium

Answer 17

Appearance &
Behaviour
Hypo- or hyper-alert. Agitated, aggressive, purposeless
behaviour.
Speech Incoherent, rambling.
Mood Low mood, irritable or anxious. Mood is often labile.
Thought Confused, ideas of reference, delusions.
Perception Illusions, hallucinations (mainly visual), misinterpretations.
181
Cognition Disoriented, impaired memory, reduced
concentration/attention.
Insight Poor

Question 18

Investigations for delirium

Answer 18

Routine investigations: Urinalysis (UTI); Bloods: FBC (infection); U&Es
(electrolyte disturbance); LFTs (alcoholism, liver disease); calcium
(hypercalcaemia); glucose (hypo-/hyperglycaemia); CRP (infection/inflammation);
TFTs (hyperthyroidism); B12, folate, ferritin (nutritional deficiencies); ECG
(cardiac abnormalities, acute coronary syndrome); CXR (chest infection);
Infection screen: blood culture (sepsis) and urine culture (UTI).
2. Investigations based on history/examination: ABG (hypoxia), CT head (head
injury, intracranial bleed, CVA), and you may consider lumbar puncture
(meningitis), EEG (epilepsy).
3. Diagnostic questionnaire (helps with diagnosis but also monitoring):
Abbreviated Mental Test (AMT): A quick easy tool (see OSCE tips 3).
Confusion Assessment Method (CAM): Usually performed after AMT (see
OSCE tips 3).
Mini-Mental State Examination (MMSE)

Question 19

Presentation of delirium

Answer 19

Sudden onset, different to usual self
Fluctuating course
Disorientation
Poor concentration, inattention
Poor STM
Abnormal perception; Hallucinations
Abnormalities of Sleep-wake cycle
Psychotic thoughts
Agitation
Emotionally labile

Question 20

DDs of delirium?

Answer 20

Dementia.
Mood disorders: depression or mania (bipolar).
Late onset schizophrenia.
Dissociative disorders.
Hypothyroidism and hyperthyroidism (may mimic hypo- and hyperactive delirium
respectively).

Question 21

Management of delirium

Answer 21

Person centred care
Identify and manage the possible underlying cause or combination of causes.
Ensure effective communication and reorientation

Question 22

Supportive management of delirium

Answer 22

Clear communication – explain what you are doing slowly and clearly, remember their STM is impaired so they might not remember. Try to use questions that need a ‘yes or no’ rather than asking them questions that rely on their memory as this can be distressing.
Reminders of the day, time, location and identification of surrounding persons.
Have a clock available.
Have familiar objects from home, especially glasses, walking aids and hearing aids.
Staff consistency - both doctors and nurses. Try not to move beds/wards.
Involve the family and carers.
Remove catheters etc where possible.
Quiet environment with low lighting.
Uninterrupted sleep – do they really need obs overnight?
Mobilise regularly with physio – NICE recommends no cot side, encourage walking/motion exercises 3x daily

Question 23

Supportive management of delirium

Answer 23

Clear communication – explain what you are doing slowly and clearly, remember their STM is impaired so they might not remember. Try to use questions that need a ‘yes or no’ rather than asking them questions that rely on their memory as this can be distressing.
Reminders of the day, time, location and identification of surrounding persons.
Have a clock available.
Have familiar objects from home, especially glasses, walking aids and hearing aids.
Staff consistency - both doctors and nurses. Try not to move beds/wards.
Involve the family and carers.
Remove catheters etc where possible.
Quiet environment with low lighting.
Uninterrupted sleep – do they really need obs overnight?
Mobilise regularly with physio – NICE recommends no cot side, encourage walking/motion exercises 3x daily