Delirium (Acute Confusion)

Question 1

What is delirium?

Answer 1

Acute brain failure

Question 2

Delirium is a syndrome consisting of…

Answer 2

1) Acute onset, typically over hours or days followed by a fluctuating course
2) Impaired attention and altered awareness
3) A variety of cognitive and neuropsychiatric disturbances

Question 3

What is the diagnostic criteria for delirium called?

Answer 3

DSM5

Question 4

What are the 5 parts of DSM5?

Answer 4

1) Disturbance in attention and awareness
2) Disturbance develops over short period of time, is a change from baseline and fluctuates in severity over the day
3) Additional disturbance in cognition
4) Disturbances in 1 and 2 are not explained by other neurocognitive disorders and are not in the context of severely reduced level of arousal e.g. coma
5) Evidence that disturbance is a direct physiological consequence of another medical condition, medication, withdrawal, toxin, or mixture

Question 5

What is the effect of delirium on dementia?

Answer 5

Increases rate of progression of dementia

Question 6

What are the predisposing factors to delirium?

Answer 6

1) Dementia
2) Cognitive impairment
3) Previous delirium
4) Functional impairment
5) Visual impairment
6) Hearing impairment
7) Comorbidity
8) > 75
9) Depression
10) Alcohol misuse

Question 7

What the the precipitating factors of delirium?

Answer 7

1) Drugs (psychoactive and sedatives + anticholinergics)
2) Physical restraints
3) Bladder catheter
4) Dehydration/electrolyte disturbance
5) Infection
6) Hip fracture
7) Major surgery
8) Pain
9) Polypharmacy
10) Constipation (can be due to codeine/morphine)

Question 8

What is the mnemonic to remember causes of delirium?

Answer 8

DELIRIUM

Question 9

What are the causes of delirium under DELIRIUM?

Answer 9

1) Drugs/Dehydration
2) Electrolyte imbalance (hypercalcaemia/hyponatraemia)
3) Level of pain
4) Infection/Inflammation (post surgery)
5) Respiratory failure
6) Impaction of faeces
7) Urinary retention
8) Metabolic disorder (liver/renal failure, hypoglycaemia)/MI

Question 10

What is the pathophysiology of delirium?

Answer 10

• Complicated
• Likely to be > 1 cause
• Cholinergic deficiency, dopaminergic excess

Question 11

What are the two types of delirium?

Answer 11

Hyperactive and hypoactive

Question 12

What are the features of hyperactive delirium?

Answer 12

1) Increased confusion
2) Hallucinations/delusions
3) Sleep disturbances
4) Less co-operative
5) Restless, agitated, aggressive

Question 13

What are the features of hypoactive delirium?

Answer 13

1) Poor concentration
2) Less ware
3) Reduced mobility/movement
4) Reduced appetite

Question 14

What is mixed delirium?

Answer 14

Mixture of hyperactive and hypoactive

Question 15

What are the % in how common the different types of delirium are?

Answer 15

20% hyperactive
40% hypoactive
30% mixed

Question 16

What is carphologia (can occur in hyperactive delirium)?

Answer 16

Tugging at bed sheets/picking at lint

Question 17

What do you need to consider when assessing delirium?

Answer 17

1) Think delirium
2) Age 65 or older
3) Cognitive impairment/dementia
4) Current hip fracture
5) Severe illness

Question 18

What are two methods for assessing delirium?

Answer 18

1) CAM (confusion assessment method)

2) 4-AT

Question 19

What are the sections of the CAM and how do you use to it diagnose delirium?

Answer 19

1) Acute onset and fluctuating course
2) Inattention
3) Disorganised thinking
4) Altered consciousness (hypo or hyper alert)
- To diagnose need 1 and 2 + 3/4

Question 20

How do you assess acute onset and fluctuating course?

Answer 20

1) Identifying change from baseline
2) Collateral history (family and staff) → has pt been more confused lately?
3) Have there been fluctuations across hours and days?

Question 21

How do you assess inattention?

Answer 21

1) Difficulty maintaining attention or shifting attention between tasks
2) May be manifested by vagueness, distracted by sounds, objects, thoughts
3) Bedside tests of attention → counting backwards numbers or months

Question 22

How do you assess disorganised thinking?

Answer 22

1) Problems making sense of what is going on
2) Misinterpreting the environment e.g. real stimulus but misinterpreting situation
3) May be hallucinations or persecutory ideas
4) Mumbling or rambling speech which is difficult to understand

Question 23

How do you assess altered consciousness level?

Answer 23

• Hyper alert → agitated, restless, aggressive, disturbed sleep
• Hypo alert → sleepy, withdrawn, no interest in environment, poor oral intake

Question 24

What is the 4-AT?

Answer 24

A brief clinical instrument for delirium detection with basic orientation questions

Question 25

What is involved in taking a full history of a delirious patient?

Answer 25

1) Ask for potential causes of delirium
2) Alcohol/drugs and medication history
3) Collateral history from family/friends/staff

Question 26

What is involved in a full examination of a delirious patient?

Answer 26

1) Full examination for causes of delirium
2) Look for infection, dehydration, sensory impairment e.g. broken glasses, hearing aid on side, external head injury
3) Baseline cognitive assessment e.g. AMT, MMSE
4) Assess for presence of delirium
5) Assess for pain → pressure sores, constipation

Question 27

What are high risk medications for delirium?

Answer 27

1) Analgesics
2) Anticholinergics
3) Antidepressants
4) Sedative-hypnotics
5) Corticosteroids
6) Dopamine agonists

Question 28

What are low risk medications for delirium?

Answer 28

1) Cardiovascular agents
2) Antimicrobials
3) Anticonvulsants
4) Gastrointestinal agents
5) Skeletal muscle relaxants

Question 29

What investigations should you do to diagnose delirium?

Answer 29

1) FBC, U&E, calcium, glucose, LFT
2) Microbiology
3) Pulse oximetry
4) ECG
5) CXR
6) Neuroimaging → subdural haemorrhage esp. in patients on blood thinners
7) Lumbar puncture
8) EEG
9) Consider ABG, drug levels, B12, TFTs, ammonia, cortisol, vitamin B12

Question 30

What are common differential diagnoses of delirium?

Answer 30

1) Depression
2) Dementia
3) Another psychotic diagnosis
4) Non-convulsive epilepsy

Question 31

How do you manage delirium?

Answer 31

1) Address acute medical issues
2) Re-orientate
3) Maintain safety
4) Promote normal sleep-wake cycle
5) Monitor symptoms of delirium and record progress

Question 32

Describe pharmacological treatment of delirium (last resort)

Answer 32

• Start low dose and review daily
• Should be short term (<1 week)
• Haloperidol → do ECG first
• Lorazepam → if antipsychotics are contraindicated
• Chlordiazepoxide for alcohol withdrawal
• Can prolong delirium if sedative

Question 33

When are antipsychotics contraindicated?

Answer 33

• Parkinson’s
• Lewy body dementia
• Seizures
• Elongated QTc (>470ms)