Delirium

Question 1

diagnosis of delirium

Answer 1

purely clinical - no diagnostic test

Question 2

agitated and restless delirium

Answer 2

hyperactive delirium

Question 3

quiet and withdrawn delirium

Answer 3

hypoactive delirium

Question 4

moving between agitated and restless, and quiet and withdrawn

Answer 4

mixed delirium

Question 5

when to suspect delirium

Answer 5

acute/subacute change in behaviour, cognition or function
if there is a Hx of cognitive impairment/depression

Question 6

onset of delirium

Answer 6

acute/subacute onset over hours-days

Question 7

hallmarks of delirium

Answer 7

fluctuating symptoms (vary in intensity over the day)
decreased attention (distractible, cannot focus or shift)
altered level of consciousness (hyper alert or drowsy or unrousable)
disorganised thinking (rambling, tangential, incoherent)
altered sleep/wake cycle
perceptual disturbance
emotional deregulation (anxiety, fear, irritability)
psychomotor disturbance

Question 8

perceptual disturbance in delirium

Answer 8

may have visual hallucination or delusions
typically persecutory, may be grandiose

Question 9

hyperactive delirium looks like

Answer 9

30% of delirium
easier to recognise, wandering, agitated, hallucinating, aggressive, resistive to care, repetitive behaviours eg. plucking at sheets

Question 10

hypoactive delirium looks like

Answer 10

25% of delirium
easiest to miss
appears quiet and withdrawn, drowsy, may be misdiagnosed as depressed, appears in a daze

Question 11

mixed delirium looks like

Answer 11

45% of delirium
most common
person may switch back and forth between states

Question 12

common times people develop delirium

Answer 12

up to a third of >65yo will develop delirium
up to 80% ICU patients
80% of patients develop delirium near death

Question 13

consequences of delirium

Answer 13

increases mortality and morbidity
critically ill patients with delirium have more than double mortality rate compared to those who do not develop delirium
prolonged hospital LOS
increased complications and cost
increased functional decline

Question 14

typical complications of delirium

Answer 14

malnutrition 🍎
fluid/electrolyte abnormalities 💦
infections 🦠
pressure injuries 🤕
decreased mobility (deconditioning)
falls and fractures
incontinence 🚽
wandering
discharge to residential care 🏡
long term cognition impairment

Question 15

long term cognitive impact

Answer 15

delirium can give rise to long term cognitive impairment
may trigger onset or worsening of underlying dementia
consider referral to Memory Clinic if undiagnosed premorbid cognitive decline

Question 16

risk factors for development of delirium

Answer 16

1. strongest risk factor is underlying dementia
2. depression/dysphoric mood
3. older age, frailty, presence of multiple comorbidities, sensory impairments, male sex, alcohol misuse, past Hx of delirium

Question 17

predisposing factors in the hospital setting that increase likelihood of developing delirium

Answer 17

use of physical restraints
malnutrition
use of urinary catheter
use of >5 medications (poly pharmacy)
any iatrogenic effect

Question 18

can delirium be prevented through pharmacology

Answer 18

little evidence of pharmacological strategies to prevent delirium

Question 19

delirium prevention

Answer 19

provide familiar staff
avoid room changes
orientation (clocks and calendar)
ensure glasses and hearing aids are worn
promote sleep hygiene
early mobilisation (twice daily)
cognitively stimulating activities
quiet environment esp. at night
good pain control
optimise nutrition and hydration
regulate bladder and bowel function
encourage family to be present (especially late afternoon/early evening when confusion is worse)
avoid physical restraints
minimise use of IDC
introduce yourself at every interaction

Question 20

who should undergo screening for delirium

Answer 20

all patients on admission to hospital with one or more risk factors

Question 21

CAM

Answer 21

confusion assessment method
for diagnosis with delirium the patient must:
display acute onset or fluctuating course AND inattention AND EITHER disorganised thinking OR altered level of aoncsciousness

Question 22

4AT

Answer 22

brief (<2 mins) standard tool for delirium detection
includes:
months backwards (attention)
alertness
AMT4 - age, DOB, place, year
scoring based on point system

Question 23

point system of the 4AT

Answer 23

greater than or equal to 4: possible delirium
1-3: possible cognitive impairment
0: delirium/severe cognitive impairment is unlikely

Question 24

reversible causes of delirium

Answer 24

medication side effects or withdrawal are the most common reversible cause
other examples: infection, hypoxia, hypo/hyperglycaemia, hypo/hyperthermia, alcohol or sedative withdrawal, anticholinergic drugs, sensory deprivation (not using glasses, hearing aids), sleep deprivation, faecal impaction, urinary retention, change of environment

Question 25

medications which can worsen cognition

Answer 25

drugs with anticholinergic effects AED anti-parkinson drugs alcohol antipsychotics BZD opiates corticosteroids cardiovascular medications (metoprolol, digoxin)

Question 26

how long does it take to recover from delirium

Answer 26

2-6 weeks

Question 27

prolonged delirium recovery

Answer 27

complete resolution can take weeks/months can be persistent (not recover) likely to be prolonged in the setting of an underlying dementia can be associated with irreversible decline in physical and cognitive function

Question 28

investigations for causes of delirium

Answer 28

ECG (ischeamia, arryhtmia) lab studies (drug screens and bacterial/viral causes) imaging (CTB, MRI CXR as guided by clinical suspicion)

Question 29

EEG for investigation of delirium

Answer 29

if suspecting epileptic activity, non-convulsive status epilepticus (NCSE), metabolic encephalopathy or encephalitis as a cause of delirium

Question 30

who should have a CT brain

Answer 30

should not be performed routinely indicated if new focal neurology, reduced conscious state not adequately explained by another cause, history of recent falls, head injury, on anticoagulant therapy consider imaging patients with non-resolving delirium where no clear cause (e.g. infection) is evident or if there is suggestion of primary CNS pathology

Question 31

mainstay of delirium management

Answer 31

identify and treat cause non-pharmacological/supportive

Question 32

when to use pharmacotherapy

Answer 32

1. degree of agitation/aggression interferes with their ability to receive essential nursing or medical care 2. behaviours threaten safety of self or others 3. anxiety/delusions/hallucinations are causing significant distress

Question 33

using opiates to treat pain

Answer 33

opiates may worsen confusion but untreated pain is a cause of delirium use lowest dose possible for adequate pain control

Question 34

best opiate to use

Answer 34

oxycodone is opiate with lowest risk of causing delirium

Question 35

worst opiate to use

Answer 35

pethidine

Question 36

drugs are not helpful for

Answer 36

calling out or wandering behaviours

Question 37

antipsychotics and BZD

Answer 37

can worsen delirium no evidence they improve prognosis only use if safety and care are compromised or for distressing symptoms

Question 38

when to use antipsychotics

Answer 38

only short term use of low dose monitor for adverse effects avoid PRN use, specify max dose in 24 hours

Question 39

examples of antipsychotics

Answer 39

haloperidol, risperidone, olanzipine, quetiapine

Question 40

choice of antipsychotic

Answer 40

olanzipine is more sedative-ish quetiapine if Lewy body dementia or Parkinson's haloperidol used most commonly and can be given IM as single dose

Question 41

should you use typical or atypical antipsychotics

Answer 41

no difference typical vs. atypical in this context

Question 42

when is quetiapine the best choice

Answer 42

for patients with levy body dementia or Parkinson's disease causes fewer extrapyramidal symptoms

Question 43

use of melatonin

Answer 43

can help sleep wake cycle abnormalities few side effects

Question 44

use of benzodiazepines

Answer 44

not first line may worsen delirium significant adverse effects single dose may be considered if no response to antipsychotic

Question 45

possible medical adverse effects of anti-psychotic

Answer 45

sedation, postural hypotension, drug induced Parkinsonism, prolonged QTc on ECG, weight gain and hyperglycaemia, neuroepelieptic malignant syndrome cardiovascular events, stroke and death

Question 46

does delirium require follow up

Answer 46

yes - pts who develop delirium may have undiagnosed dementia or MCI - possible cognitive decline following delirium - can develop depression after delirium - should not drive until delirium resolves

Question 47

onset of delirium vs. dementia

Answer 47

delirium: acute dementia: insidious

Question 48

course of disease in dementia vs. delirium

Answer 48

delirium: fluctuating dementia: progressive

Question 49

consciousness in dementia vs. delirium

Answer 49

delirium: altered dementia: clear

Question 50

psychotic episodes in delirium vs. dementia

Answer 50

delirium: common, perceptual disturbances and auditory/visual hallucinations in up to 50% dementia: only in late disease

Question 51

orientation in dementia vs. delirium vs. depression

Answer 51

dementia: impaired delirium: impaired depression: normal