11 - Delirium

Question 1

What is delirium?

Answer 1

Disturbance in attention

Reduced awareness

Develops over a short period,

Fluctuate in severity throughout the day.

No pre-existing explanation

Is a direct consequence of a another medical condition.

Question 2

What often happens to a P’s sleep-wake cycle in delirium?

Answer 2

It gets reversed

Question 3

What cognition impairments are characteristic of delirium?

Answer 3

Hallucinations, disorientation and memory loss are characteristic of delirium

Question 4

What are the subtypes of delirium?
Which is most common?

Answer 4

Hyperactive
Hypoactive
Mixed (most common)

Question 5

Which subtype of delirium is associated with higher mortality?

Why?

Answer 5

Hypoactive - often mistaken for something else as less obvious and less distressing.

Worse outcome as associated with reduced oral intake, immobility with inc risk of pressure sores and hospital acquired infection.

Question 6

What other diseases present similarly to hypoactive delirium?

Answer 6

Severe depression
Post-ictal phase
Non-convulsive status epileptics
Encephalitis

Question 7

What other diseases present similar to hyperactive delirium?

Answer 7

Dementia
Psychosis

Question 8

How can you tell the difference between delirium and dementia?

Answer 8

Question 9

Why is diagnosis of delirium important?

Answer 9

Extremely common & associated with adverse outcomes

Question 10

What percentage of patients with delirium still have symptoms at six months?

Answer 10

20%

Question 11

What is solifenacin used for?

Answer 11

Treatment for overactive bladder - is an anti-cholinergic medication.

Question 12

How is the PINCHME mnemonic used in delirium?

Answer 12

Identifies possible causes of delirium
- Pain
- Infection
- Nutrition
- Constipation
- Hydration
- Medication
- Environment

Question 13

When thinking about the cause of delirium - what is it important to remember?

Answer 13

That any medical illness can precipitate delirium - not just geriatric illnesses.

AND

Most cases of delirium are multifactorial

Question 14

What are the predisposing factors to delirium?

Answer 14

Older age
Dementia or cognitive impairment
Frailty

Question 15

What are the precipitating factors of delirium?

Answer 15

Question 16

How long after stopping alcohol does delirium tremens start?
What symptoms are seen?

Answer 16

3-10 days
Commonly associated with tactile hallucinations, formication
Can cause seizures and is potentially life threatening

Question 17

How is severity of stressor linked to delirium?

Answer 17

The severity of the stressor needed to cause delirium decreases with frailty, worsening cognition and age. The younger the patient, the more severe illness needed to develop delirium.

Question 18

What is the neurotransmitter hypothesis of delirium?

Answer 18

That alterations in NT production / function are part of the cause of delirium!
- inc dec ACh
- XS Dopa, NOR & Glutamate
- Altered levels of histamine serotonin & GABA

Question 19

In terms of neurotransmitters what type of state is delirium thought to be?

Answer 19

Hypocholinergic - hyperdopaminergic state

Question 20

What role does ACh have in delirium?

Answer 20

ACh thought to be reduced
- linked to EEG slowing
- reduced ACh thought to increase delirium - however low levels of ACh are not found in all cases of delirium

Question 21

What role do histamine receptors have in delirium?

Answer 21

H1 and H2 antagonists can cause sedation and delirium

Question 22

How does dopamine affect delirium?

Answer 22

Thought to be increased levels of dopamine in delirium - however there is an inconsistent response in Ps to antipsychotics.

Question 23

What is the role of NOR in delirium?

Answer 23

Question 24

Which drugs are associated with delirium?

Answer 24

Question 25

What is the neural network disconnectivity theory of delirium?

Answer 25

Brain is connected in functional networks - when stressed these can fail to connect = failure of normal brain function. Thought this might be a final driver in delirium.

Question 26

Which is the preferred tool recommended by NICE for diagnosing delirium?

Answer 26

4AT

Question 27

What is SQiD?

Answer 27

Single question in delirium - Is this P more confused than before? Very crude measure.

Question 28

What does new confusion score in NEWS2?

Answer 28

3 points

Question 29

Apart from 4AT and SqID - what is another useful tool for identifying delirium in Ps?

Answer 29

Short CAM

Question 30

How do we manage delirium?

Answer 30

Full comprehensive medical assessment - identify all possible causes of delirium Systematically address any causes Correct sensory impairment Re-orientation Optimise hydration, bowels and bladder function Undertake comprehensive medication review

Question 31

How do we prevent delirium?

Answer 31

Question 32

What leaflet can be given to Ps to support them with their care in cases of delirium or dementia?

Answer 32

The This is Me Leaflet

Question 33

What method should you employ to deal with distressed delirious patients?

Answer 33

Apparently not any form of sedation for the patient - although you yourself might want to pop a diazepam. Use verbal and non-verbal techniques to de-escalate the situation.

Question 34

When can you give drug treatments in delirium for distressed patients? What should you give?

Answer 34

Can give Dx if P is - Distressed - A risk to themselves or other - Verbal and non-verbal de-escalation techniques have failed Start with Haloperidol - lowest dose for shortest time DO NOT give in Parkinson's or LBD - use benzos instead. Antipsychotics may be used if severe hallucinations / delusions Melatonin may be given for sleep disorders

Question 35

What is the median recovery period for a P with delirium? What does duration depend on? What percentage of Ps will have Sx at 3 months?

Answer 35

Median duration = 1 week Duration depends on severity of the precipitant 1/3 of Ps have Sx at 3m

Question 36

How long would delirium Sx have to persist in order to diagnose a chronic cognitive impairment?

Answer 36

6 m +

Question 37

What is a significant drop in BP defined as?

Answer 37

A reduction of 20/10 mmHg within 3 mins of standing

Question 38

What are the four features of the CAM (Confusion Assessment Method) Alogorithim?

Answer 38

(1). Acute onset and fluctuating course - is there an acute change in mental status? Does the behaviour fluctuate? (2). Inattention - doe the patient have trouble keeping track of what is said? Easily distractible? (3). Disorganised thinking - is their thinking disorganised, rambling, irrelevant or illogical? (4). Altered levels of consciousness - alert, vigilant (hyper alert), lethargic (drowsy by easily roused), stuporose (difficult to arouse) or comatose (unrousable)? Diagnosis of delirium requires presence of 1 & 2 and either 3 or 4.