Delirium (EL) Flashcards
Define delirium.
Syndrome of acute confusion characterised by fluctuations in attention, cognition and awareness
Acute fluctuating change in mental status with inattention, disorganised thinking and altered levels of consciousness
Which demographics are most susceptible to delirium? (2)
- elderly patients >65y
- hospitalised patients
What is delirium typically secondary to? (9)
- infection (UTIs, pneumonia)
- metabolic (hypercalcaemia, hypoglycaemia, hyperglycaemia, hyponatraemia, dehydration)
- change in environment
- severe pain
- trauma (hip fractures)
- drugs
- alcohol withdrawal
- constipation
- urinary retention (may be due to BPH - suprapubic distension and weakness)
What acronym can be used to help us remember the causes of delirium?
PINCH ME
- Pain
- Infection
- Nutrition
- Constipation
- Hydration
- Medication
- Environment / Electrolytes
Which brain regions might be involved in delirium? (6)
- prefrontal cortex
- subcortical structures
- thalamus
- basal ganglia
- lingual gyri
- frontal, fusiform and temporoparietal cortex
What might contribute to delirium pathophysiology? (3)
- cholinergic deficiency, dopaminergic excess and other neurotransmitters
- interleukins 1&2 and TNF-alpha and interferon
- chronic hypercortisolism (as induced by chronic stress secondary to illness or trauma)
Define delirium tremens.
Extreme form of acute alcohol withdrawal developing around 72 hours after ceasing alcohol intake
How does delirium tremens present?
Hallucinations and fluctuating consciousness levels
How do we treat delirium tremens? (2)
Chlordiazepoxide and Pabrinex (IV thiamine)
What are the clinical features of delirium? (7)
- disturbance in attention
- change in cognition
- develops over short period of time
- disturbance caused by direct physiological consequences of general medical condition, substance intoxication/withdrawal
- hallucinations
- agitation
- severity of Sx fluctuates throughout day and worsens in evening
What differentiates delirium from dementia?
ACUTE alteration in level of awareness and attention (decreased consciousness)
What are the types of delirium? (4)
- hypoactive (25%) - decreased psychomotor activity - withdrawn, lethargic, slow to respond, lack of interest
- hyperactive (75%) - increased psychomotor activity - restless, agitation, hallucinations, inapt behaviour
- mixed delirium
- sub-syndromal delirium - partially resolved/incomplete forms of delirium
Compare delirium vs dementia.
- onset: sudden, prodromal phase might precede VS insidious
- course: rapid and fluctuating, hours to days VS slowly progressive deterioration, months to years
- level of consciousness: decreased VS intact
- attention: impaired (fluctuating) VS usually alert, impaired in advanced phase
- memory: recent memory loss VS recent then remote memory loss
- thought process: disorganised VS impoverished
- hallucinations: present (often visual or tactile) VS can be present in advanced disease
- psychomotor activity: increased/decreased VS usually normal
- EEG: usually abnormal VS usually normal
- reversibility: reversible VS irreversible
What is needed for diagnosis of delirium?
All 4 of below AND not accounted for by previous dementia/other conditions:
- disturbance in attention (lethargy, distractability)
- change in cognition (memory deficit, disorientation, language disturbance)
- develops over short period of time (usually hours to day and fluctuates)
- disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication or substance withdrawal
What are some risk factors for delirium? (5)
- age >65
- background of dementia
- significant injury
- frailty or multimorbidity
- polypharmacy
What bedside test can we do for delirium in GP?
General Practitioner Assessment of Cognition (GPCOG)
What is the main screen we do for delirium and what does it consist of (5)
Confusion screen:
- TFTs (hypothyroidism)
- B12
- folate
- glucose (hypoglycaemia)
- bone profile (hypercalcaemia)
What investigations can we do for delirium to look for the underlying cause? (6)
- urinalysis (UTI)
- CXR (infection)
- CRP/WCC
- serum glucose (hypo/hyperglycaemia)
- bladder scan (urinary retention)
- electrolytes
What might EEG show in delirium?
Diffuse slowing of cortical activity
What cognitive screening is done for delirium?
AMTS (6 or less suggests delirium/dementia)
What are some differential diagnoses for delirium?
- dementia - chronic impairment of memory with aphasia, apraxia, agnosia and/or disturbances in executive function
- depression - similar to hypoactive delirium
- mental illness
- anxiety
- thyroid disease - similar to hyper/hypoactive delirium
- non-convulsive epilepsy / temporal lobe epilepsy
- Charles Bonnet syndrome - visual hallucinations
- pain
- infections - acute systemic infection, meningitis/encephalitis
- nutrition - dehydration, constipation
- medications - anticholinergics, TCAs, opiates, steroids, analgesics, anti-Parkinson drugs
- metabolic - hypo/hyperglycaemia, hypoxia, hypercapnia, hypo/hypernatraemia
- hepatic encephalopathy
- acute urinary obstruction
- renal failure
What are the main forms of management of delirium? (4)
- treat underlying cause e.g. acute urinary retention –> catheterise
- patient comfort and symptom control - fever control, pain management, hydration
- reducing confusion - reorient to time, place and person
- treating agitation/high severity - 1st line antipsychotics –> haloperidol 0.5mg OR olanzapine
How can we modify the environment (reorientation) in delirium? (5)
- regular cues
- easily visible clocks and calendars
- continuity of care
- visits from friends/family
- normalise sleep-wake cycle
How do we manage agitation/high severity delirium?
- 1st line antipsychotics - haloperidol 0.5mg/respiradone/olanzapine
- contraindicated in Parkinson’s as they worsen symptoms –> lorazepam (benzodiazepine) may be used instead
- careful reduction of Parkinson’s medication may be helpful, if Sx require urgent treatment then atypical antipsychotics quetiapine and clozapine are preferred
- initially offer these orally, if refused and patient poses immediate physical risk to other patient, IM route is justified
