Delirium Flashcards
What is delirium?
Also known as acute confusional state. It is an organic reaction which can be differentiated from chronic conditions, such as dementia.
What are the risk factors of delirium?
• Recent surgery:
- Narcotic pain medication - Benzodiazepines - Hypnotics - Anticholinergics • Underlying diseases - Dementia - Constipation - Pneumonia - Urinary tract infections
Chronic fatigue
Who is delirium most commonly seen in?
It is most often seen in those patients with prior vulnerabilities such as post-operative patients, the elderly, and the very young.
What is the differential diagnosis of delirium?
Withdrawal from alcohol/drugs, mania, post-ictal or if agitated, consider psychosis or anxiety. All are readily distinguished on history-taking. Always consider dementia (which usually has an insidious onset and occurs in clear consciousness ie without drowsiness etc).
Normal grief process - onset can be clear as person recently died therefore grieving is clear.
What is the epidemiology of delirium?
Common on surgical and medical wards (10-20%)
What are the causes of delirium?
Most often the cause is: infection, drugs (benzodiazepines, opiates, anticonvulsants, digoxin, L-dopa); U&E increase or decrease; hypoglycaemia; decreased PaO2; alcohol withdrawal; trauma; surgery (esp. if pre-op Na+ reduction or sensory loss)
What is the clinical presentation of delirium?
• Cognitive function: worsened concentration, slow responsiveness, confusion and disorientation in time (doesn’t know day or year)
• Perception: visual or auditory hallucinations
• Physical function: reduced mobility, reduced movement, restlessness, agitation, changes in appetite, sleep disturbance. Often these behaviours are fluctuating: varying between quiet or drowsy with occasional agitated outbursts so that you are called when he is “disrupting the ward”
Social behaviour: lack of cooperation with reasonable requests, withdrawal, or alterations in communication, mood and/or attitude. As part of their ACS, patients may become delusional (usually poorly developed delusions), for example accusing staff of plotting against them.
What are the 3 main types of delirium?
ACS can be hyperactive (agitated and upset), hypoactive (drowsy and withdrawn), or mixed. On a bust ward, it is the hyperactive ACS patients who cause disruption and gain attention while those with hypoactive ACS are not noticed.
How can you prevent delirium?
• Recognising that they are on several opioids
• Help them to feel comfortable
- Reduce extra noise & stimulation
- Glasses, hearing aids
- Good daily routine
Healthy meals, stay hydrated, stool regularly, stay active, healthy sleep habits
• Post surgery, use non-opiates
Avoid restraints - haloperidol/ 2nd gen antipsychotics that can help with symptoms.
How would you investigate a patient with delirium?
U&E, FBC, blood gases, glucose, cultures (blood, MSU), LFT, ECG, CT, CXR, LP. If a cause is not identified, consult a neurologist urgently.
What is the management of delirium?
Should consider a holistic approach:
• Find the precipitating cause and treat this, and other exacerbating factors
• Optimize supportive surroundings and nursing care
• Avoid sedation unless there is extreme agitation, risk, or needed for investigations to take place. Give antipsychotics in first instance as benzodiazepine tend to worsen delirium with exception of alcohol withdrawal.
• If needed, consider haloperidol 1-10mg/24h or olanzapine 2.5-10mg/24h (smallest dose possible, esp. if elderly). Monitor BP. Wait 20 min to judge IM effects (side effects: BP increase/decrease, stroke, insomnia, dyspepsia)
• Regular clinical review and follow up.
What is the prognosis of delirium?
ACS can have serious consequences (such as increased risk of dementia and/or death) and, for people in hospital, may increase their length of stay in hospital and their risk of new admission to long-term care. If there is no past psychiatric history, and in the setting of physical illness or post-surgery, and ACS is particularly likely.
What are the associated symptoms of delirium?
• Delirium can increase the risk of falls:
- Patients 6 times more likely to fall
- They are disorientated, agitated and confused.
- Falls can lead to broken bones, head injuries, bruises and bleeds.
Causes to longer hospitalizations + higher mortality rates.
