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13.01.08 Delirium

Definition
  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        • From out of date dairy products (can't read the label)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

 

 

1

2

3

4

5

1

Remembering things about family and friends, eg occupations, birthdays, addresses

Much improved

A bit improved

Not much change

A bit worse

Much worse

2

Remembering things that have happened recently

Much improved

A bit improved

Not much change

A bit worse

Much worse

3

Recalling conversations a few days later

Much improved

A bit improved

Not much change

A bit worse

Much

worse

4

Remembering her/his address and telephone number

Much improved

A bit improved

Not much change

A bit worse

Much worse

5

Remembering what day and month it is

Much improved

A bit improved

Not much change

A bit worse

Much worse

6

Remembering where things are usually kept

Much improved

A bit improved

Not much change

A bit worse

Much worse

7

Remembering where to find things which have been put in a different place from usual

Much improved

A bit improved

Not much change

A bit worse

Much worse

8

Knowing how to work familiar machines around the house

Much improved

A bit improved

Not much change

A bit worse

Much worse

9

Learning to use a new gadget or machine around the house

Much improved

A bit improved

Not much change

A bit worse

Much worse

10

Learning new things in general

Much improved

A bit improved

Not much change

A bit worse

Much worse

11

Following a story in a book or on TV

Much improved

A bit improved

Not much change

A bit worse

Much worse

12

Making decisions on everyday matters

Much improved

A bit improved

Not much change

A bit worse

Much worse

13

Handling money for shopping

Much improved

A bit improved

Not much change

A bit worse

Much worse

14

Handling financial matters, eg the pension, dealing with the bank

Much improved

A bit improved

Not much change

A bit worse

Much worse

15

Handling other everyday arithmetic problems, eg knowing how much food to buy, knowing how long between visits from family or friends

Much improved

A bit improved

Not much change

A bit worse

Much worse

16

Using his/her intelligence to understand what’s going on and to reason things through

Much improved

A bit improved

Not much change

A bit worse

Much worse



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

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

Prevention

  • 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

Notes

  • 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

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