Think Delirium

Question 1

What is delirium?

Answer 1

• Acute brain failure
• A syndrome of: acute onset,typically over hours or days ;followed by a fluctuating course;with impaired attention& altered awareness; and a variety of cognitive & neuropsychiatric disturbances
• Up to 30% delirium may be preventable
• Tends to be multifactorial
• Can be hyperactive,hypoactive or mixed

Question 2

How can we diagnose delirium?

Answer 2

DSM-5 diagnostic criteria.

A.) A disturbance in attention & awareness
B.) disturbance develops over a short period of time, fluctuates in severity throughout the day & representas a change from baseline awareness & attention
C.)an additional disturbance in cognition (eg memory, perception, visuospatial ability, disorientation, language)
D.)the disturbances mention in A&C cannot be explained by another preexisting,established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
E.)There is evidence from the history, physical examination, or laboratory findings
that the disturbance is a direct physiological consequence of another medical
condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a
medication), or exposure to a toxin, or is due to multiple etiologies.

Question 3

What may be the outcomes of delirium?

Answer 3

Increased rates of:

• Cognitive impairment& functional disability
• Length of hospital stay
• Institutionalization
• Death
• Falls
• If you already have dementia the addition of delirium also increases the rate of progression of your dementia( doubles the rate of cognitive decline in first year after hospital admission with delirium)

Question 4

Outline the pathophysiology of delirium

Answer 4

• Complicated
• Unlikely to be a single cause
• neurotransmitters implicated: cholinergic deficiency; dopaminergic excess

Question 5

What can lead us to think delirium may be present ?

Answer 5

pneumonic= DELIRIUM
Drugs(withdrawal/toxicity,anticholinergics)/dehydration
Electrolyte imbalance
Level of pain
Infection/inflammation(post surgery)
Respiratory failure(hypoxia,hypercapnia)
Impaction of faeces
Urinary retention
Metabolic disorder(liver/renal failure, hypoglycemia)/ MI

Question 6

Outline the characteristics of hyperactive delirium.

Answer 6

• Makes a person feel restless,agitated, aggressive
• increased confusion
• Hallucinations/delusions
• Sleep disturbance
• Less co-operative

Question 7

Outline the characteristics of hypoactive delirium.

Answer 7

• Makes a person withdrawn,quiet,sleepy
• Poor concentration
• Less aware
• Reduced mobility/movement
• Reduced appetite/poor oral intake

Question 8

Is there an association between age and delirium?

Answer 8

-Generally; the older you are, the more likely it is. >75years

Question 9

Outline the Delirium-Confusion assessment method.

Answer 9

1.) Acute onset and fluctuating course
2.) Inattention (distractible, cannot communicate)
3.) Disorganised thinking (illogical, rambling)
4.) Altered consciousness (hypo-hyperalert)
To diagnose delirium you need 1 AND 2 + 3 or 4

Question 10

What bedside tests can we use to test attention?

Answer 10

• Counting 20 to 1 backwards

- Counting months of the year backwards (say forwards first)

Question 11

What is 4-AT?

Answer 11

brief clinical instrument for delirium detection

Question 12

What is the differential diagnosis for delirium?

Answer 12

• Depression
• Dementia(but delirium may co-exist and always treat for delirium)
• Another psychiatric diagnosis
• Non-convulsive epilepsy
• Wernicke’s encephalopathy & korsakoff’s syndrome

Question 13

Outline some of the predisposing factors of delirium

Answer 13

• dementia
• cognitive impairment
• visual impairment
• hearing impairment
• previous delirium
• functional impairment
• comorbidity or severity of illness
• older age (>75yrs)
• depression
• alcohol misuse

Question 14

Outline some of the precipitating factors of delirium

Answer 14

• hip fracture
• drugs (psychoactive &sedatives)
• physical restraints
• bladder catheter
• dehydration/electrolyte disturbance
• infection
• major surgery
• pain
• polypharmacy
• constipation

Question 15

How can we assess a pt for delirum

Answer 15

1.) FULL HISTORY
-collateral history
-asking for potential causes of delirum
-drug and medication history
2.) FULL EXAMINATION
-causes of delirum
-look for infection,dehydration, sensory impairment
-baseline cognitive assessment (AMT, MMSE)
-

Question 16

what is the 4-AMT

Answer 16

Abbreviated mental test-4

1. )AGE
2. )DOB
3. )PLACE
4. )YEAR
   - ask the pt the questions above to see if they get them right

Question 17

Outline the high-risk medications for delirium

Answer 17

1.)ANALGESICS
-NSAIDs, opiods
2.) ANTI-CHOLINERGICS
-atropine, benztropine, diphenhydramine, scopolamine
3.)ANTIDEPRESSANTS
-Mirtazapine, SSRIs, TCAs(tricyclic antidepressants)
4.) SEDATIVES-HYPNOTICS
-Benzodiazepines, propofol
5.)CORTICOSTEROIDS
-Hydrocortisone, prednisone, methylprednisone, dexamethasone
6.) DOPAMINE AGONISTS:
-Amantadine, bromocriptine, levodopa,
pergolide, pramipexole, ropinirole

Question 18

What investigations will we use when finding out if a pt has delirum

Answer 18

• FBC,LFT, calcium, U&Es,glucose
• microbiology
• pulse oximetry
• ECG
• CXR
• consider ABG,drug levels, B12, TFTs,ammonia,cortisol, vitamin B12

Question 19

Which investigations can we use to target the cause of the delirious pt?

Answer 19

1. )NEUROIMAGING:
   - low yield if other identified causes of delirum
   - focal neurology
   - head injury(falls)
2. )LUMBAR PUNCTURE(if signs of meningism or encephalitis)
3. )EEG-electroencephalogram (selected pts)
   - Seizures
   - differentiation from other disorders (psychiatric)

Question 20

Distinguish between the 3 conditions a.) delirium, b.) dementia and c.) depression 
stating the 
1.) ONSET
2.)ALERTNESS
3.)ATTENTION 
4.)SLEEP
5.)THINKING
6.)PERCEPTION

Answer 20

DELIRIUM:
1= sudden (hours to days)
2=fluctuates, sleepy or agitated
3=fluctuates, difficulty concentrating, easily distracted
4.)changes in sleep pattern, often more confused at night
5.)disorganised thinking; jumping from one idea to the next
6.)illusions,delusions and hallucinations common

DEMENTIA:
1=usually gradual (over months)
2=generally normal
3=generally normal
4=can be disturbed-night time wondering & confusion
5=problems with thinking and memory,may have problems finding the right word
6=generally normal(may have visual hallucination with lewy body dementia)

DEPRESSION

1. )gradual (over weeks to months)
2. )generally normal
3. )may have difficulty concentrating, easily distractible
4. )early morning wakening
5. )slower thinking, preoccupied negative thoughts of hopelessness, helplessness or self depreciation
6. )generally normal

Question 21

How can you use re-orientation to manage a delirious patient?

Answer 21

• involve family
• correct sensory impairment
• avoid moving around wards or between wards

Question 22

Outline the management of a delirious pt (MDT approach)

Answer 22

1. )ADDRESS ACUTE MEDICAL PROBLEMS
2. )RE-ORIENTATE
3. )MAINTAIN SAFETY
   - dont restrain
   - avoid catheters
   - mobilise(safely) & think about falls risk
4. )PROMOTE NORMAL SLEEP-WAKE PATTERN
   - discourage napping during the day
   - non-pharmacological sleep protocol
5. )MONITOR SYMPTOMS OF DELIRIUM AND RECORD PROGRESS & HOPEFULLY RESOLUTION
6. )EXPLAIN DELIRIUM TO PT&FAMILY (OFFER WRITTEN INFO)

Question 23

How can we optimise the environment in order to manage a delirious pt?

Answer 23

-Avoid moving the patient between or around a ward
(especially at night)
-Calm and quiet
-Natural light
-Clocks/calendars
-Eliminate unnecessary noises/bleeps/alarms especially
at night
-Think carefully about using bedrails
-Maintain safe uncluttered environment to reduce falls
risk

Question 24

Outline the pharmacological management of delirium

Answer 24

-Should only be considered if all other non-pharmacological methods have failed and pt is severely distressed by delirium symptoms, pt is a risk to self or others or pt requires urgent medical interventions
-Always document why medication is being used
-start low dose and review daily
-treatment should be short term (<1 week)
-HALOPERIDOL(do ECG first- QTc interval)
-LORAZEPAM (if antipsychotics contraindicated, e.g.
Parkinson’s disease/parkinsonism, Lewy Body
dementia, seizures, elongated QTc (>470ms)
-CHLORDIAZEPOXIDE: usually used for alcohol withdrawal

Question 25

Why should an ECG be performed before use of haloperidol

Answer 25

-cos the degree of QTc prolongation is correlated significantly with use of haloperidol

Question 26

Outline persistent delirium

Answer 26

-Defined as a cognitive disorder that
met criteria for delirium on/after admission to hospital
and continued to meet criteria at discharge and beyond
-Presence of pre-existing dementia is the strongest risk factor for persistent delirium
-Delirium is a risk factor for developing dementia and on discharge from hospital symptoms of delirium should be documented on discharge summary and appropriate follow up organised

Question 27

Outline the low-risk medications for delirum

Answer 27

1.)CARDIOVASCULAR AGENTS:
Antiarrhythmics, beta-blockers, clonidine, digoxin
2.)ANTIMICROBIALS: Acyclovir, aminoglycosides, amphotericin B,
cephalosporins, fluoroquinolones, linezolid,
macrolides, penicillin, sulfonamides
3.)ANTICONVULSANTS: Carbamazepine, phenytoin, valproate
4.)GI AGENTS:
Antiemetics, H2
-receptor antagonists
5.)SKELETAL MUSCLE RELAXANTS:
-Baclofen