Delirium is an acute disturbance in attention, cognition, and awareness. It is diagnosed clinically using tools like the CAM. The presentation can be hyperactive or hypoactive. Risk factors include older age, frailty, cognitive impairment, and multiple medications. Prevention strategies focus on reorientation, mobility, sleep, and limiting psychoactive medications. Treatment aims to address underlying causes, though antipsychotics are not usually recommended. Delirium can increase mortality and institutionalization, so prompt recognition and management are important.

1. IN-PATIENT DELIRIUM
A practical approach
Hiba Antar, F1 Neurology

2. DEFINITION OF DELIRIUM
• According to the ICD-10 it’s:
“An aetiologically non-specific organic cerebral syndrome characterized by concurrent
disturbances of consciousness and attention, perception, thinking, memory, psychomotor
behavior, emotion and the sleep-wake schedule. The delirious state is transient and of
fluctuating intensity.”

3. DEFINITION OF DELIRIUM
• It’s a clinical syndrome. Characterized by:
• Acute and Fluctuating disturbances in attention & cognition = AMS, ACS, encephalopathy
• Inattention is its Hallmark
• Patient cannot think clearly, pay attention….
• Dementia is chronic, in the absence of inattention!!
• A family member is needed to differentiate b/w delirium & dementia.
• Every one is at risk yet older patient with pre-existing neurocognitive disease are at higher
risk due to their more “Vulnerable brain”
• It’s due to ongoing inflammation & neurodegeneration of the brain, with elevated biomarker
of the neuronal damage/ NfL
• Don’t think of delirium as a dichotomy.
• Assess the severity and know the duration
• Treatment goal is to reduce the severity & to shorten the duration

4. 2 TYPES OF DELIRIUM
Hyperactive delirium
• S/S such as visual, auditory or tactile
hallucinations. Patient might be
agitated, or Combative.
• De-escalating strategies are important
Hypoactive delirium
• More common, yet under-recognized
• “Quiet delirium”
• Patient may present with loss interest,
difficulty interacting, DPOi, drowsy….

5. DELIRIUM RISK FACTORS
Age > 70 yo
History of neurocognitive disease
Frailty
History of delirium, stroke, neurological disease or falls
Severe illness Injury or recent surgery, especially hip fracture
Substance misuse
Polypharmacy (>4 medications) and high risk medications
(anticholinergic, opiates, benzodiazepines)
Sensory impairment Multiple ward moves

6. RECOGNIZING DELIRIUM
• It’s challenging, especially if the patient presents without a known cof=genitive baseline.
• Up to 30% of cases may have no identifiable cause and normal investigation results do
not exclude Delirium.
• Always ask the family about his mental status, when did they notice the alteration, does
he has any pre-existing neurocognitive diseases.
• It’s a clinical diagnosis, yet many tools are can help.
• CAM
• Ultra brief CAM
• Only 2 questions!!!
• 4-AT

7. UB-CAM

8. 3D-CAM

9. WHAT TO ORDER?
• It’s a multifactorial syndrome
• Use a time-checklist
• First DO a clinical assessment for your patient!!!
• Take history & do a Physical exam!!
• Ask the relative for any recent changes!
• What is his ROA
• Ask for vitals: BP, HR, SpO2, HGT, & temperature
• Review medications
• Draw blood for: CBCD, chem9, U/A, ABGs
• Other test: Ammonia, ECG, CXR, Neuroimaging, EEG, LP according to the contest.
• Note: Vitb12, TSH and folic acid are usually the w/u of dementia!

10. CONSEQUENCES OF DELIRIUM
• Delirium is a/w :
• functional decline,
• higher mortality,
• institutionalization
• Incident dementia
• The higher the severity & and the longer the duration the worse are
the outcomes.

11. PREVENTION
• It can be prevented!!!
• It’s everyone’s responsibility and should be part of the hospital culture
• Identify patients at risk!!
• P:reventative Bundles
Oral fluid
repletion &
Appropriate Poi
Orientation
activities
Activities that
engage the
patient
Early & safe
mobilization
Vision &
hearing
assistance
Sleep
enhancement
Infection
enhancement
Pain
management
Regulate
bladder & bowel
function
Minimize
psychoactive
meds!!!!

12. NON-
PHARMACOLOGICAL
MEASURES FOR
DELIRIUM

13. THE USE OF ANTIPSYCHOTICS
• Current evidence doesn’t support the use of antipsychotic meds for the treatment nor the prevention of
delirium.
• Use to be limited for case where the patient &/or staff are at risk.
• Recommended pharmacological treatment are:
• Haldol
• 0.5-1mg IM/IV q30 min prn max 5 mg /day
• contraindications: Lewy Body Dementia/Parkinson’s Disease/ Prolonged QTc interval/already prescribed medications
which prolong the QTc interval.
• Haloperidol should not be used alongside other drugs that prolong QTc.
• Quetiapine (Seroquel) (the least anti-dopaminergic activity)
• Safe in patient with PD and lewy body dementia
• Olanzapine
• Risperidone
• Note: Quetiapine (Seroquel) has the least anti-dopaminergic activity followed by Olanzapine & risperidone
• If anti-psychotic are CI  Use benzodiazepine

14. D/C RECOMMENDATIONS
• Deliriumcan take weeks to fully resolve.
• If the etiology have been managed than the patient may be safe for discharge.
• Discharging patient home to a more familiar environment with close follow up may
have additional benefits.
• A diagnosis of dementia should not be made within 6 months of delirium, as its s/s
might last for up to 6 month!

15. TAKE HOME MESSAGES
• Delirium is a clinical syndrome!! Yet different tools can help in its identification
• CAM, 4AT, Ultra-brief CAM
• Its severity & duration matters for long-term clinical outcomes
• It’s a/w ongoing brain inflammation, & neuronal damage.
• It increases rates of dementia, and functional decline.
• 30-40% can be PREVENTED, by multiple prevention strategies including behavioral
strategies.
• Etiologies are usually multifactorial. DO NOT just check UA
• Avoid antipsychotics unless staff safety is at risk!!!!

16. SUMMARY OF DX APPROACH