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Delirium

From Mediwikis

Managing Delirium Out of Hours, by AEME

Delirium is an acute reversible confused state that is underdiagnosed. It is common in any state where the body is under more stress than normal, such as during an infection and post-surgery. It can be present even with entirely normal blood test results. It can be exacerbated by confusing situations such as new places, lots of new people or at night.
Patients typically lose track of time, a minute can seem like a day and vice versa when delirious.
There is a high mortality (20%) associated with delirium.

Also known as Acute Confusional State, symptoms include:

  • Disordered thinking
  • Euphoria/fearful/angry
  • Language impairment
  • Illusions/delusions/hallucinations
  • Reversal of the sleep wake cycle
  • Inattention
  • Unaware/disorientated
  • Memory deficits

Keep in mind the Stress Vulnerability Model in that individuals who are vulnerable only need a small insult to become delirious, but anyone can become delirious if the insult is big enough.

Risk Factors

  • Extremes of age
  • Severe illness
  • Poly-pharmacy
  • Baseline cognitive impairment
  • Frailty
  • Sensory impairment (e.g. poor hearing/vision leading to disorientation)

Causes

Common causes are PINCH ME, there is often a combination of causes:

  • Pain
  • Infection/Intoxication
  • Nutrition (lack of adequate)
  • Constipation
  • Hydration/Hypoxia
  • Medication- Antihistamines, Steroids, Antispasmodics, Opiates, L-Dopa, Anticonvulsants, Sedatives, Recreational.
  • Environmental

Plus rarer ones you don't want to miss (WHIMP):

  • Wernicke's encephalopathy
  • Hypertensive encephalopathy
  • Intracranial haemorrhage
  • Meningitis/encephalitis
  • Poisoning

Diagnosis

A diagnosis of delirium is based on using the Confusion Assessment Method (CAM), for a diagnosis of delirium a patient requires 1 and 2, alongside 3 or 4.

  1. Acute onset/fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Altered level of consciousness (vigilant, agitated, lethargic, stupor)

Management

Consider the underlying cause from the patients history, and perform appropriate investigation and treatment for those. Alongside this:

  • Do not physically restrain the patient
  • Reduce any medication that isn't necessary, especially any of the above
  • Sedation via antipsychotics (haloperidol, olanzapine, risperidone) may be needed only if the patient is highly distressed
  • Don't give benzodiazepines - these will worsen the delirium except in alcohol withdrawal delirium where they are first line (Chlordiazepoxide)

Non-Pharmacological Management

The only interventions for delirium that have any evidence are multi-component (and not solely pharmacological) interventions.[1]

Try to minimise the confusion the patient faces while focusing on the underlying cause. This can be achieved with a person-centred approach, including any of the following good practices for good medical and nursing care:

  • Low stimulus environments
  • Encourage family to visit
  • Ensure good hydration
  • Mobilise the patient early
  • Identify cause and treat (if possible)
  • Side room
  • Keep the same few nurses looking after the patient to reduce number of strangers around
  • Keep routine similar to what they are used to (meal times, waking etc.)

References

  1. Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563. DOI: 10.1002/14651858.CD005563.pub3.