Delirium Flashcards
(28 cards)
What is the DSM-V definition of delirium?
Delirium is an acute disturbance in attention and awareness, accompanied by a change in cognition (such as memory deficit, disorientation, language or perceptual disturbance). It develops over a short period (hours to days), tends to fluctuate during the course of the day, and is a direct physiological consequence of a medical condition, substance intoxication/withdrawal, or multiple causes.
What are the three subtypes of delirium?
- Hyperactive: Agitated, aggressive, hallucinating.
- Hypoactive: Withdrawn, quiet, often missed.
- Mixed: Alternating features of both.
Describe hyperactive delirium.
Characterized by restlessness, agitation, hallucinations, delusions, mood lability, and inappropriate behaviour. Easily recognized due to overt motor activity.
Describe hypoactive delirium.
Characterized by decreased responsiveness, apathy, slowed speech, lethargy. Often underdiagnosed and mistaken for depression or dementia.
What does ‘ABCDE I-HIT Me’ stand for in delirium workup?
A: Airway (assess GCS),
B: Breathing (hypoxia, hypercapnia),
C: Circulation (shock or hypertensive encephalopathy),
D: Disability & Drugs (withdrawal, hypoglycaemia, toxidromes),
E: Electrolytes & Exposure (fever, infection, hypoNa, Ca, Mg),
I: Intracranial pathology (ICH, mass lesion, seizure, meningitis),
H: Hepatic/renal failure, Wernicke’s,
I: Infection (UTI, pneumonia, meningitis, neurosyphilis),
T: Thyroid/adrenal causes,
Me: Metabolic (acidosis, uraemia, dehydration).
What are common metabolic causes of delirium?
Uraemia, dehydration, hyper/hyponatraemia, acidosis, hypoglycaemia, liver failure, and thyroid dysfunction.
What bedside investigations are crucial for delirium?
ABG/VBG (acidosis, CO2 retention), BSL (hypoglycaemia), FBC (infection, anaemia), EUC/CMP (electrolytes), CRP (inflammation), LFTs, TFTs, blood film.
When should a CT brain be ordered in delirium?
When there are focal neurological deficits, signs of raised ICP, unexplained new-onset delirium, seizure activity, or failure to improve with initial treatment.
When is an EEG useful in delirium?
To exclude non-convulsive status epilepticus (NCSE), especially in hypoactive delirium or fluctuating conscious states.
What are key non-pharmacological interventions for delirium?
Reorientation aids (clocks, calendars), promote sleep hygiene, minimize noise/light at night, mobilize early, ensure hydration and nutrition, remove tethers like IDC/IVs, involve family, restore vision/hearing aids.
When should pharmacological treatment for delirium be considered?
Only if the patient poses a risk to themselves or staff, or if their agitation is interfering with essential care (e.g. pulling out lines, preventing ventilation).
What are the safest first-line pharmacological agents for delirium?
Atypical antipsychotics like quetiapine (25–50 mg PO), olanzapine (5–10 mg SL/IM), or risperidone (0.5–2 mg PO), preferred for lower EPS risk and better tolerability.
What are the risks of typical antipsychotics like haloperidol and droperidol?
QT prolongation, extrapyramidal symptoms, neuroleptic malignant syndrome, hypotension. Caution in elderly or those with cardiac disease.
What is the role of dexmedetomidine in delirium?
Alpha-2 agonist used in ICU for sedation. Reduces duration of delirium, allows arousable sedation, preserves respiratory drive. Titrate 0.2–1.4 mcg/kg/hr.
When are benzodiazepines appropriate for delirium?
Only in cases of alcohol or benzodiazepine withdrawal. Otherwise, they may worsen or precipitate delirium.
What drug preserves airway and is useful in severe agitation, but may worsen psychosis?
Ketamine: a dissociative anaesthetic useful for rapid control of severe agitation or stimulant toxidrome. May exacerbate hallucinations.
What ICU drug requires airway protection but is useful in refractory sedation?
Propofol: IV sedative-hypnotic used for deep sedation, useful in intubated patients. Risk of hypotension and propofol infusion syndrome.
List three key Code Black safety steps.
- Ensure staff safety and retreat if needed.
- Activate duress alarm or emergency call.
- De-escalate if safe, or proceed with physical/chemical restraint.
What are core de-escalation techniques in behavioural disturbance?
Use calm tone, non-threatening body language, acknowledge concerns, give choices, set boundaries respectfully, avoid confrontation.
How should physical restraint be performed?
Assign a team leader, allocate one person per limb and head, communicate throughout, ensure reassessment, and document thoroughly.
What are the non-modifiable risk factors for delirium?
Age >65, pre-existing dementia, alcohol dependence, high illness severity (APACHE), nursing home residence.
What are modifiable delirium risk factors?
Benzodiazepines, opiates, sleep disruption, dehydration, constipation, immobility, electrolyte imbalance, polypharmacy.
Which screening tools are recommended for ICU delirium?
CAM-ICU and ICDSC: validated tools for detecting delirium in ventilated and non-ventilated ICU patients.
