Delirium

Question 1

What is delirium?

Answer 1

An acute, transient and reversible state of confusion, usually the result of other organic processes (infection, drugs, dehydration), the onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.

Question 2

What are the types of delirium?

Answer 2

Hyperactive and
Hypoactive

Fluctuation between the two is common.

Question 3

Symptoms of Hyperactive delirium?

Answer 3

This is the “typical” delirium picture:

• Agitation
• Delusions
• Hallucinations
• Wandering
• Aggression

Question 4

What are the symptoms of Hypoactive delirium?

Answer 4

Much easier to miss, often confused with depression. Sx include:

• Lethargy
• Slowness with everyday tasks
• Excessive sleeping
• Inattention

Question 5

Causes and risk factors for delirium?

mnemonic

Answer 5

CHIMPS PHONED

• Constipation
• Hypoxia
• Infection
• Metabolic disturbance
• Pain
• Sleeplessness
• Prescriptions
• Hypothermia/ pyrexia
• Organ dysfunction
• Nutrition
• Environmental changes
• Drugs

Question 6

Why do we need to identify delirium?

Answer 6

• Common condition
• 50%not recognised and treated
• Medical emergency
• 2 fold increase in mortality in case matched controls
• 20% mortality at 30 days
• 8 day increase (on average) in length of stay
• More likely to develop HAI/pressure ulcers

Question 7

What tool is useful for assessing delirium?

Answer 7

AMTS - abbreviated mental test score
or
4AT - is a four question subset of the AMT

Could also consider more formal MMSE/ ACE III

Question 8

How do you do a 4AT?

Answer 8

ALERTNESS
normal = 0
mild sleepiness for <10 secs after waking, then normal = 0
clearly abnormal = 4

AGE, DOB, LOCATION, YEAR
no mistakes = 0
1 mistake = 1
2 or more mistakes/ untestable = 2

ATTENTION
months of the year backwards
7 or more correct = 0
<7 correct or refuses to start = 1
untestable (unwell drowsy, abnormal) = 2

ACUTE CHANGE OR FLUCTUATING COURSE
significant change or fluctuation in alertness, cognition, other mental function over last two weeks and still present in 24 hrs
No = 0
Yes = 4

Question 9

Ix in delirium?

Answer 9

Vitals
CT Head?

FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g. hypoglycaemia)
Blood cultures (e.g. sepsis)

CXR

Urine tests
UTI is a very common cause of delirium in the elderly. Urine dipstick without clinical signs is NOT satisfactory to diagnose urinary sepsis as a cause of delirium. Do MSU.

Question 10

Management of delirium?

Answer 10

Identify and treat underlying cause.

Supportive management.

Environmental adaptation.
(familiar objects, clock, noise levels)

Medication
(avoid where possible)

Post-discharge
(follow-up, chance or recurrence, PTSD)

Question 11

Medication that could be used in delirium?

Answer 11

Aim to keep patient safe with least restrictive method.

Drugs can worsen delirium.

Haloperidol (oral, IM or IV) low dose of 0.5mg repeated in 30mins if no response.

IF Benzos then lorazepam 0.5mg starting dose. Or olanzepine 2.5mg

Question 12

Mental Capacity Act 2005 give what powers?

Answer 12

Deprivation of Liberty Safeguards.

Can restrain patients if they lack capacity and it is in the best interests of their physical needs.

Question 13

4 broad categories of causes of delirium?

Answer 13

INTRACRANIAL (stroke, haemorrhage)
SEPSIS (infection, fever, pain - pneumonia, skin, UTI, GI)
IATROGENIC (medications, surgery, GA etc)
METABOLIC (electrolytes, dehydration, constipation, )