Red Book - Delirium

Question 1

Define delirium

Answer 1

An acute alteration in conciousness and awareness that fluctuates over time

Features:
	Disorded thinking
	Reduced attention
	Abnormal sleep/wake
	Abnormal psychomotor activity
	Abdnormal perceptions
	Changed emotional behaviour

Question 2

DSM criteria

Answer 2

Four criteria:

Disturbed conciousness with reduced focus, or cannot sustain attention

Change in cognition (memory loss) or perceptual disturbance

Happens over a short period of time and fluctuates throughout day

Evidence that these changes occur physiological consequences of a medical condition
	OR the delirium has more than one aetiology

Question 3

ICD 10 criteria

Answer 3

1) clouding of conciousness —> reduced awareness of environment, change in attention

2) disturbed cognition —> impaired reall and recent memory (remote memory intact)
Disorientated in time place person

3) Psychomotor disturbance (hypo to hyperactice, startled ++, increased reactions)
4) Disturbed sleep-wake cycle —> insomnia, dreams and nightmares
5) Rapid onset and fluctuant
6) evidence from hix/O/E that systemic disease or cerebral disease is responsible

Question 4

Pathophysiology of delirium

Answer 4

Neurotransmitter imbalance
Reduced Ach
Increased dopamine

INCREASED NEURONAL EXCITABILITY

Possible cerebral microvascular dysfunction due to inflammatory mediators
OR global failure of oxidative metabolism —> cerebral insufficiency

Question 5

Types of delierium

Answer 5

Hyper, hypo and mixed

Hyper - 1%
Confused, agitated, combative, paranoid

Hypo 35%
Inattention, stupour, withdrawn, ?Mistake for depressed

Mixed 64%

Question 6

Risk factors

Answer 6

Patient, Illness and iatrogenic

Patient
	Age
	Co-morbids
	Pre-existing cognitive impairment/psych hx
	Alcohol / substance misuse

Illness
	High APACHE
	Sepsis
	Hypoxia
	Metabolic impaired - acidosis, Na balance
	Surgery (CPB!)

Iatrogenic
Sleep wake cycle - environment, noise etc
Sedatives - benzos
Anticholinergic meds

Question 7

Consuequences of delirium

Answer 7

Short, medium and long

Short term
Adverse events - extubation, line pulled

Medium
Increased LOS in ICU/hopspital
Increased MV
Increased mortality (3x risk factor)

Long
PTSD
Cognitive impairment

Question 8

Diagnosis/Screening methods

Answer 8

CAM-ICU (Confusion Assessment method)

ICDSC (Intensive Care Delirium Screening Checklist)

Question 9

Reducing the risk

Answer 9

Use of bundles
e.g. ABCDE

Awake and breathing - sedation holds and SBT —> reduces sedation and MV needs

Choice of sedative -> minimise use of benzos

Delirium monitoring —> CAM-ICU

Early mobilisation
Environmment - orientation etc

Good sleep hygiene

Remove invasive devices once not needed

Question 10

Management

Answer 10

Non-pharmacology and pharma

Non - sedation holds, SBTs, re-orientation, family visits etc

Pharm

Antipysch - haloperidol, olanzepine, quetiapine, rispiridone

Dexmedotomidine (a2 agonist)

Question 11

Evidence for Dex Med

Answer 11

DahLIA trial - dexmed vs placebo

Reduced vent free days at day 7
Non significant reduction is LOS

UNDERPOWERED

Midex/prodex

Double blind RCT 
Dex was non-inferior to midaz or propofol
Duration of sedation shorter compared to midaz (but not propofol)

Question 12

CAM-ICU - describe

Answer 12

1) acute onset or fluctuation
Have they changed from baseline.

2) inattention test - letters SAVEAHAART
3) Altered level of concious —> RASS
4) Disoragnisned thinking (stones in water)

NEED 1 plus 2 and 3 OR 4

Question 13

ICDSC

Answer 13

Checklist done by nursing staff obvserving behaviours through the day

Altered level of concious RASS etc

Inattention

Disorientated

Hallucination

Psychomotor agitation

Mood

Sleep disturbed

Fluctuation