Delirium

Question 1

What are other terms used for delirium?

Answer 1

Acute confusional state, altered mental status, toxic/metabolic encephalopathy.

Question 2

What are long-term risks associated with delirium?

Answer 2

2x death, 2.4x institutionalization, 12.5x new dementia.

Question 3

What is the most widely used tool to diagnose delirium?

Answer 3

Confusion Assessment Method (CAM).

Question 4

What 4 features are assessed in CAM?

Answer 4

1. Acute change/fluctuation, 2. Inattention, 3. Disorganized thinking, 4. Altered level of consciousness.

Question 5

What is the 4AT tool?

Answer 5

A brief delirium screener for general medicine patients (~90% sensitivity/specificity).

Question 6

What is the 3D-CAM tool?

Answer 6

A 3-minute diagnostic tool for CAM-defined delirium (~95% accuracy).

Question 7

What is the most common subtype of delirium?

Answer 7

Hypoactive delirium (~50%).

Question 8

Which delirium subtype has worse prognosis?

Answer 8

Hypoactive delirium.

Question 9

What neurotransmitter deficiency is linked to delirium?

Answer 9

Cholinergic deficiency.

Question 10

Which inflammatory markers are associated with delirium?

Answer 10

CRP, interleukin-6, TNF-α.

Question 11

What are predisposing risk factors for delirium?
(Outpatient)

Answer 11

Age, dementia, impaired ADLs, multimorbidity, alcohol abuse, male sex, sensory impairment.

Question 12

What are precipitating risk factors for delirium? (Physical)

Answer 12

Acute illness, infection, pain, meds (anticholinergics, sedatives, opioids), urinary retention, constipation, anemia, restraints, bed rest.

Question 13

How does delirium affect dementia progression?

Answer 13

Without dementia: risk of incident dementia. With dementia: accelerates decline.

Question 14

When is post-op delirium most likely to occur?

Answer 14

Peak onset POD 1, peak prevalence POD 2.

Question 15

What intraoperative approach reduces delirium risk?

Answer 15

Light sedation with propofol (vs. usual care).

Question 16

What is key in history-taking for delirium evaluation?

Answer 16

Time course of cognitive changes and relation to events/medications.

Question 17

What are routine labs for delirium evaluation?

Answer 17

CBC, electrolytes, renal, glucose, UA, LFTs, tox screen, drug levels, ABGs, cultures, CXR, ECG.

Question 18

When is brain imaging indicated in delirium?

Answer 18

Head trauma or new focal neurologic findings.

Question 19

When are EEG/CSF helpful?

Answer 19

If seizures or meningitis suspected.

Question 20

Which medications should be reduced or eliminated with delirium?

Answer 20

Alcohol, anticholinergics, antihistamines, benzos, barbiturates, opioids (esp. meperidine aka demerol), H2 blockers, antipsychotics, anticonvulsants, antiparkinsonian drugs.

Question 21

What is first-line medication for agitation in delirium?

Answer 21

Low-dose haloperidol (unless Parkinson’s/Lewy body dementia).

Question 22

Which drug is preferred for delirium in Parkinson’s disease or Lewy body dementia?

Answer 22

Quetiapine.

Question 23

When are benzodiazepines indicated in delirium?

Answer 23

For alcohol or sedative withdrawal.

Question 24

What is the HELP program for delirium prevention?

Answer 24

Hospital Elder Life Program: targets cognitive impairment, sleep deprivation, immobility, sensory impairment, dehydration.

Question 25

What non-drug strategies help prevent delirium?

Answer 25

Sleep hygiene, minimize psychoactive drugs, proactive geriatric consult.

Question 26

What is the Choosing Wisely recommendation regarding restraints in delirium?

Answer 26

Avoid physical restraints for behavioral symptoms.

Question 27

What is the Choosing Wisely stance on benzos in delirium?

Answer 27

Avoid benzos or sedative-hypnotics as first-line for insomnia, agitation, or delirium.

Question 28

Elderly man with acute lethargy, ↓ oral intake, grimacing with mouth pain → diagnosis?

Answer 28

Delirium.

Question 29

Best initial treatment for delirium in CHF patient pulling lines?

Answer 29

Encourage family presence at bedside.

Question 30

What is the safest pharmacologic option for an agitated delirium patient with Parkinson’s disease?

Answer 30

Quetiapine.