Delirium

Question 0

A diagnosis of delirium requires

Answer 0

Disturbance in consciousness and disruptions of attention
Changes in cognition or perceptual disturbance not accounted for by existing illness
Acute onset with fluctuations over the day
Must be occurring secondary to another medical condition

Question 1

Delirium is also know as

Answer 1

Acute confusional state
Acute brain syndrome/dysfunction
Toxic-metabolic encephalopathy 
ICU psychosis
Cerebral insuffiency

Question 2

Delirium is

Answer 2

An organic cerebral syndrome of acute dysregulation of neuronal membrane function due to impairment of the oxidative metabolism.
This causes a neurobehavioural syndrome characterised by concurrent disturbance of consciousness, attention, perception, thinking, memory, psychomotor behaviour and sleep.

Question 4

Features of delirium

Answer 4

Central feature is global impairment of consciousness
Associated features include:
- lack of awareness of surroundings (disorientation in time and space)
- problems with attention, memory or speech
- may have visual hallucinations
- duration less that six months
- at least one sleep cycle disturbance
- psychomotor disturbances
- evidence of underlying pathology

Question 5

Delirium occurs in the

Answer 5

Elderly
Medically Ill 
sensory impairment
Very young (febrile delirium)
Post op (esp cardiac)
Burns victims
Benzo dependent
Pre-existing dementia
Polypharmacy

Question 5

Metabolic causes of delirium

Answer 5

Drugs (withdrawal)
Endocrine changes (thyroid, adrenal)
Electrolytes (Na,Ca, dehydration)
Vitamins (B12, thiamine)
Pain

Question 6

Causes of delirium

Answer 6

Infections
Metabolic
Organ failure
Cerebrovascular 
Neoplastic
Trauma 
Substance misuse
Delirum Tremens or alcohol induced delirium is separate.

Question 7

Delirium due to organ failure

Answer 7

Liver
Renal (uraemia in dialysis)
Hypoxia in resp failure, suppression in over-sedation/anaesthesia
Head injury

Question 8

Cerebrovascular causes of delirium

Answer 8

Stroke or TIA
Hypertensive encephalopathy
Hypotension
DIC or TTP

Question 9

Treating delirium

Answer 9

Treat underlying condition

Close observation of at risk people

Question 11

Managing delirium

Answer 11

If agitated –> quite dim room (avoid unnecessary sedation)
If calm but confused –> good lighting, visible clues to orientation, simple explanations of procedures
Treat underlying cause
Also - continuity of care and support by family and friends

Question 12

Consequences of Delirium

Answer 12

50% mortality at one year and may be a marker of subsequent dementia

Question 13

Subtypes of delirium

Answer 13

Hyperactive – agitation, delusion and disorientation.
Hypoactive – reduced motor activity, lethargy. Poor prognosis
Mixed - can present with a mixed picture or vary from hypo- to hyper active etc

Question 14

Delirium in hospital

Answer 14

Medically Ill (10-20% of inpatients, 15-33% will experience post-op delirum and 70-80% of ITU cases)

Question 15

Sleep wake cycle disturbances in delirium

Answer 15

Insomnia, inversion of sleep cycle, nocturnal worsening, nightmares which continue as hallucinations

Question 16

Psychomotor disturbances

Answer 16

Rapid unpredictable shifts in levels of activity
Increased reaction time
Increased or decreased speech
Enhanced startle reaction

Question 17

Sedatives in delirium

Answer 17

Lorazepam (0.5-1mg up to 4mg/day)
Haloperidol 0.5-1mg max 4mg/day
Risperidone 1-4 max 4mg/day
Olanzapine 2.5-5 max 20mg/day
Quetiapine 12.5-25mg max 100mg/day