Delirium Flashcards
Define delirium.
Delirium (sometimes called ‘ACUTE confusional state’) is
an acute, FLUCTUATING encephalopathic syndrome of
- INATTENTION,
- impaired level of CONSCIOUSNESS, and
- disturbed COGNITION.
How common is delirium?
- 10-30% of acute adult inpatients aged 65+
- Up to 30% of new onset on acute wards
- 80% ICU
- 20% in care homes
SO very common.
1-2% prevalence in primary care
What are the causes of delirium?
- Pain
- Infection
- Constipation
- Hydration/hypoxia
- Medication/metabolic/drugs
- Electrolytes (e.g. hyponatraemia)
- Environment e.g sleeplessness
- Organ dysfunction (hepatic or renal impairment)
- Hypothermia/pyrexia
PInCH MEE OH
What are the risk factors for delirium?
- Advanced age
- Dementia (often undetected)
- Impaired ADLs
- Immobility
- Sensory impairment e.g. no hearing aid
- Urinary catheterization
- Malnutrition
- Alcohol
- Depression
What are the 3 subtypes of delirium?
Hypoactive - patient will be very withdrawn, quiet and sleepy; inactive or reduced motor activities or seem to be in a daze
Hyperactive - patients will be restless, agitated and may display aggressive behaviour; may have hallucinations, be fearful or uncooperative
Mixed - patient will display signs of hypo- or hyper-active delirium
What are the symptoms of delirium?
Hyperactive, hypoactive or mixed
Transient delusions, poorly explained - often persecutory with associated ideas of reference
Autonomic hyperactivity - sweating, tachycardia and dilated pupils
Disturbance of sleep-wake cycle - more alert during evening and drowsy during the day
How is delirium diagnosed?
- Impaired attention and awareness
- AND either:
-
Perceptual disturbance (visual illusions, hallucinations) OR
* *Cognitive** disturbance (memory, speech, orientation deficit)
-
Perceptual disturbance (visual illusions, hallucinations) OR
- AND the symptoms must develop over a short period of time (hours/days) and fluctuate during the day
- AND there must be evidence that this is related to a physical cause (not a pre-existing psychiatric disorder)
What is the CAM?
Confusion Assessment Method -
- Feature 1: acute onset of mental status changes or a fluctuating course
- Feature 2: Inattention
- Feature 3: disorganised thinking OR Feature 4: Altered level of consciousness
= DELIRIUM
i.e. 1+2+3/4, sensitivity ~100%, specificity ~95%, PPV ~94% = very good tool for assessment
DSM V criteria for delirium
A. A disturbance in attention (ie reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness and tends to fluctuate in severity during the course of the day.
C. An additional disturbance in cognition (eg memory deficit, disorientation, language, visual spatial ability or perception).
D. The disturbances in Criteria A and C are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as a 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
How do you assess someone with delirium initially?
- MSE to confirm diagnosis
- Physical examination to find any underlying cause
What investigations would you do for someone with delirium? (What is the delirium screen?)
- Bloods: FBC, U&Es, TFTs, folate, Vit B12, Ca2+
- Blood cultures - rule out infection
- Urinalysis
- ECG
- CXR
- CT head/MRI
What is the management of delirium?
Conservative - make the environment as comfortable as possible e.g. same nurses, dark, quiet
Early diagnosis - if not involve psych liaison
Treat underlying cause, correcting any fluid or electrolyte abnormalities
Medication:
1st line - sedative haloperidol 0.5mg (caution in Parkinson’s or Lewy body dementia)
2nd line - olanzapine or short acting benzodiazepine
What % of delirium is undiagnosed?
50% never recognised
What is the prognosis with delirium?
37% die within 6 months
43% have reversible cognitive impairment
Only 1 in 4 recover significantly to doing ADLs
How long does delirium usually take to resolve?
6-12 weeks
Compare and contrast onset, progression, duration, mental state and behaviour etc in delirium vs dementia.
