Delirium

Question 1

Define delirium

Answer 1

aka Acute confusion state

• Disordered thinking: slow, irrational, rambling
• Euphoric: fearful, depressed, angry
• Lanuage impaired
• Illusions/ delusions/ hallucinations
• Reversal of sleep-awake cycle
• Inattention
• Unaware/ disorientated
• Memory deficits

Question 2

Outline the causes of delirium

Answer 2

DELIRIUMS

• Drugs
• Eyes, ears & other sensory deficits
• Low O2 states (MI, stroke, PE)
• Infection
• Retention (of urine or stool)
• Ictal state (after seizure)
• Underhydration/ undernutrition
• Metabolic causes (DM, post-op, sodium)
• (S) Subdural haematoma

Question 3

Outline the differentials for confusion

Answer 3

Confusion is a symptom;

• Delirium (acute confusional state in previously well patient due to acute problem)
• Dementia (continueing confusion for months)
• Delirium superimposed on dementia (acute confusional state in a patient with previous cognitive impairment whos become suddenly much worse)
• Acute functional psychosis

Question 4

How is delirium assessed?

Answer 4

1. Confusion Assessment Method (CAM) screening instrument, requires all 3;
   
   1. Acute onset & fluctuating course
   2. Inattention (unable to count down 20 to 1 & cant maintain attention or shift attention)
   3. Disorganised thinking OR altered consciousness
2. Six item cognitive impairment test (6CIT)
   
   1. ​​Year? [0/4]
   2. Month? [0/3]
   3. Memorise address (ask at end)
   4. Time now? [0/3]
   5. 20 to 1 [0/2/4]
   6. Months backwards [0/2/4]
   • Repeat address back to me [0/2/4../10]
   • Range 0-28
     
     • 0-7: probably normal
     • 8-9: minimal cognitive impairment
     • 10-28: likely dementia

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Question 5

Outline the management of delirium

Answer 5

• Environment - quiet side room, appropriate lighting, clocks & calenders, hearing aids & classes available, continuity of care
• Avoid restraints
• Haloperidol (anti-psychotic) or lorazepam (benzodiazepine)