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Delirium:

DSM IV

Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.

A change in cognition or the development of a perceptual disturbance that is not better


accounted for by a preexisting, established, or evolving dementia.

The disturbance develops over a short period of time (usually hours to days) and tends to
fluctuate during the course of the day.

There is evidence from the history, physical examination, or laboratory findings that the
disturbance is caused by a medical condition, substance intoxication, or medication side effect.

Additional features that may accompany delirium and confusion include the following:

Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with increased


sympathetic activity, and impairment in sleep duration and architecture.

Variable emotional disturbances, including fear, depression, euphoria, or perplexity.

Epidemiology
Nearly 30 percent of older medical patients experience delirium at some time during hospitalization.
Among older surgical patients, the risk for delirium varies from 10 to greater than 50 percent; the
higher figures are associated either with frail patients (eg, those who have fallen and sustained a hip
fracture) or complex procedures such as cardiac surgery.
Risk factors dementia/stroke/parkinsons (others = polypharmacy especially psychoactive drugs,
infection, dehydration, immobility, malnutrition, bladder catheters)
Causes
Predisposing factors (increase susceptibility to delirium):

Age, dementia/cognitively impaired, CVS/CVD, psychiatric comorbidities, vision/hearing impaird,


functional dependency, dehydration/malnurtrition, drugs or illicit drugs or ETOH

Precipitating factors:

Metabolic malnutrition/dehydration, electrolyte disturbance, anaemia, hypoxia, hypercapnoea,


hypoglycaemia,endo
Infection esp. resp and UTI
Medications anticholinergics, dopaminergics, opioids, steroids, polypharmacy
Vascular TIA/STROKE/MI
Pain/post-op/post-traumatic/immobilisation/ substance intoxication or withdrawal

Hx recent febrile illness/organ failure/medication list/alcoholism/drug abuse/recent depression


O/E such as jaundice/state of hydration/ needle tracks/ ketotic or alcohol or fetor hepaticus smell of
breath/bitten tongue or post. Dislocation of shoulder suggesting convulsive seizure. Neuro exam
excluding e.g. stroke
Confusion Assessment Method (CAM)

Feature
Acute onset and fluctuating course

Assessment
Usually obtained from a family member or

nurse and shown by positive responses to the


following questions:
"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?"

Inattention
Shown by a positive response to the following:
"Did the patient have difficulty focusing
attention, for example, being easily distractible
or having difficulty keeping track of what was
being said?"

Disorganised thinking
Shown by a positive response to the following:
"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?"

Altered level of consciousness

Overall how would you rate the


patients level of consciousness?
Normal = alert
Hyperalert = vigilant
Drowsy, easily aroused = lethargic
Difficult ot arouse = stupor
Unarousable = coma

Clinical presentations
Disturbance of consciousness - distractibility, drowsy, lethargic or hypervigilance (less
common in elderly)
Change in cognition memory loss, disorientation, difficulty in language and speech, misidentify people, hallucinations with lack of insight
Temporal course develops over hours to days, persists days to months with sundowning
(may have prodromal period of fatigue/sleep
disturbance/depression/restlessness/irritability/hyperarousal to light and sound)
NB: most common presentation in elderly is withdrawn, quiet state
DDX:

Focal neurological syndromes - Wernickes aphasia (dont comprehend or obey + seem


confused but problem only with language), bifrontal lesions such as from tumour or
trauma (lack judgement + poor memory + incontinence + labile emotion)
Non-convulsive status Epilepticus
Dementia
Depression (poor sleep, poor attention, agitation) or Mania or psychosis

Management
Medical ensure patient has adequate oxygenation, hydration, nutrition, electrolytes normal,
constipation and pain treated, overview of medications to assess whether any should be
ceased and investigate underlying cause such as infections. Haloperidol can be considered if
patient is extremely unsettled.
Non-medical - avoid unnecessary movement of patient and allow patient to be placed close
to the nurses station for observation. Ensure there are natural lighting from the outside and
clocks so the patient can orientate themselves to the time of the day. Dates and the name of
the hospital, the ward and the bed is useful too. Pictures of family and gifts can be placed
around the bed. Have recognisable faces such as regular nurses or their family at the bedside.
Verbal and non-verbal assurances can be delivered to calm the person. Consider removing
unnecessary constraints such as cannulas/catheters/NGT. Physical restraints should be
avoided due to risk of increased agitation and injury