12. Delirium
Transient global disorder of
cognition
Medical emergency
Affects 20% patients on general
wards
Affects 30% of elderly medical
patients
Associated with increased mortality,
increased nursing, failed rehab and
delayed discharge
13. Presentation
Acute + relatively sudden onset
(over hours to days)
Decline in attention-focus,
perception and cognition
Change in cognition must not be
one better accounted for by
dementia
Fluctuating time course of delirium
helps to differentiate
14. Characterised by:
Disorientation in time, place +/- person
Impaired concentration + attention
Altered cognitive state
Impaired ability to communicate
Wakefulness – insomnia + nocturnal
agitation
Reduced cooperation
Overactive psychomotor activity –
irritability + agression
15. Diagnosis
Cannot be made without knowledge
of baseline cognitive function
Can be confused with
1. dementia – irreversible, not assd
with change in consciousness
2. depression
3. psychosis – may be overlap but
usually consciousness + cognition not
impaired
16. Differentiating features of delirium and
dementia
Features Delirium Dementia
Onset Acute Insidious
Course Fluctuating Progressive
Duration Days – weeks Months - years
Consciousness Altered Clear
Attention Impaired Normal (unless
severe)
Psychomotor
changes
Increased or
decreased
Often normal
Reversibility Usually Rarely
17. Risk factors in elderly
Age >80
Extreme physical frailty
Multiple medical problems
Infections (chest + urine)
Polypharmacy
Sensory impairment
Metabolic disturbance
Long-bone #
General anaesthesia
18. Risk factors
Dementia is one of the most
consistent risk factors
Underlying dementia in 25-50%
Presence of dementia increases risk
of delirium by 2-3 times
19. Causes
Severe physical or mental illness or any
process interfering with normal
metabolism or function of the brain
21. Pathophysiology
Not fully understood
Main theory = reversible impairment of cerebral
oxidative metabolism + neurotransmitter
abnormalities
Ach – anticholinergics = cause of acute
confusional states + Pts with impaired cholinergic
transmission (eg Alzheimers) are more
susceptible
Dopamine – excess dopamine in delirium
Serotonin – increased in delirium
Inflammatory mechanism – cytokines eg
interleukin-1 release from cells
Stress reaction + sleep deprivation
Disrupted BBB may cause delirium
23. Management
1. Identify + treat underlying cause
(return to pre-morbid state can take
up to 3 weeks)
2. Complete lab tests +
investigations eg. FBC, CRP, U+Es,
BM, LFTs, TFTs, B12, MSU, CXR
3. Rule out EtOH withdrawl
4. Assume an underlying organic
cause
24. Management
5. Ensure adequate hydration +
nutrition
6. Use clear, straightforward
communication
7. Orientate the patient to
environment + frequent
reassurance
8. Identify if environmental factors
are contributing to confused state
25. Management
Disturbed, agitated or
uncooperative patients often require
additional nursing input
Medication should not be regarded
as first line treatment
Consider medication if all other
strategies fail but remember all
psychotropic meds can increase
delirium + confusion
26. Medications
Benzodiazepines
Lorazepam 0.5-1mg tds orally
Shorter half life than diazepam +
effective at lower doses
S/E - Respiratory depression,
increased risk of falls, hypotension
Not for long term use
27. Medications
Antipsychotics
Avoid in PD
Haloperidol 0.5-1mg
S/E – cardiac, avoid in patients with
hypotension, tachycardia + arrhythmias,
extrapyramidal
Recent evidence suggests not to use in
patients with dementia or risk of CVD due to
increased risk of cerebral ischaemia
3X increase in risk of stroke when Risperidone
used in older patients with dementia
28. Medications
Dementia with Lewy Bodies
Severe reactions to antipsychotic drugs
that can lead to death
Due to extrapyramidal effects
Urgent psychiatric opinion
29. Medication
Review regime every 48h
Will not improve cognition
Can reduce behavioural disturbance
Start with lowest dose possible +
increase gradually
Offer orally first
Use as ‘fixed dose’ regime
31. Outpatient Care
Memories of delirium are variable
Educate patient, family + carers
about future risk factors
Elderly patients can require at least
6-8 weeks for a full recovery
For some patients the cognitive
effects may not resolve completely
32. RUH Algorithm for diagnosis + management of delirium in older adults