1. Disturbed consciousness
2. Change in cognition
3. Acute onset and fluctuating course
4. Cause by a medical condition or treatment

Urgency

• Many LIFE-THREATENING conditions can cause delirium
• => Assess as a priority
• Especially if young, healthy
  
• May need to aggressively treat the underlying cause 

Pathogenesis

• 1. Medications
• Sedatives
• Steroids
• Steroid psychosis : If high dose for a long time
• Opioids
• Antihistamines
• Incl. OTC
• Digoxin
• Lithium
• 2. Infection
• 3. Metabolic
• Electrolytes
• Hypercalcaemia
• Cancer
• Unlikely to be from hyperparathyroidism (slower rise => adaptation)
• Hyponatraemia
• Hypernatraemia
• Hypophosphataemia
  
• Refeeding syndrome
• Brain can't make enough ATP
• Hypomagnesiumaemia
• cf Use is fitting (opposite effect)
  
• Endocrine
• Diabetes
• Hypoglycaemia, HHS, DKA
• Thyroid storm
• Hypothyroidism
• Cushing's
• Addison's
• 4. Failure
• Heart, resp, renal, liver
• 5. CNS
• Meningitis
• Beware atypical presentations in the elderly
• e.g. Temp. may be low as well as high
• Listeria is common is elderly (as well as infants)
• From out of date dairy products (can't read the label)
• SDH, psychiatric condition, transient global amnesia (TGA), epilepsy, hypertensive encephalopathy
• 6. Physical
• Dehydration
• Pain
• Don't forget to give decent pain relief for hip fractures!
• Catheters
• Use condom catheter or pads
• Lines
• Hypo/hyperthermia

Differentials

• Dementia
• Stroke
• Frontal lobe
• Wernicke's
• Verbal diarrhoea
  
• Occipital
• Cortical blindness => Seeing snakes
• Non-convulsive status epilepticus
• Primary psychiatric illness
• Psychosis
• Depression
• Bipolar
• Schizophrenia

Confusion Assessment Method (CAM)

• Feature 1: Acute Onset and Fluctuating Course
• Is there evidence of an acute change in mental status from the patient’s baseline?
  
• Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
• Feature 2: Inattention
• Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
• Feature 3: Disorganized thinking
• Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
• Feature 4: Altered Level of consciousness
• This feature is shown by any answer other than “alert” to the following question:
• Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])
• The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4

IQ code

• For collateral history
• Compare with the patient 10 years ago
  

• INVOLVE PHYSIOS EARLY
• Avoid
• Precipitating factors
  
• Treat
• Underlying cause
  
• Support
• Aspiration, hydration, nutrition, mobility, skin + pressure care, incontinance
  
• Control
• Behaviour
  

• Haloperidol
• 1st choice
• Lorazepam
• Short half life
• Quetiapine
• If pre-existing dementia
• NOT risperidone/olanzapine
  
• Stroke risk
  

• Orientation protocols
• Mandatory on psych wards
• Cognitive stimulation
• Keep on general ward
• Beware of over- and under- stimulation
• Don't move at night
• Early mobilisation
• Minimise restraint
• Adequate hydration
  

• ACS vs Delirium
• ACS is hypoactive
• Delirium is hyperactive
• Aim for <6 drugs in elderly care
• Differentials co-exist in 50% of cases
• Focal neurology or trauma => Immediate CT head
• Delirium => 2x mortality
  
• The key intervention is PHYSIOTHERAPY