1. What is delirium?
Delirium is a mental state in
which you are confused,
disoriented, and not able to
think or remember clearly. It
usually starts suddenly. It is
often temporary and treatable
2. OVERVIEW
• Delirium is common in older people, but is
often not recognized
• It can present with a wide range of
symptoms and signs
• Patients at high risk of developing delirium
can be identified and it can sometimes be prevented
• Treatment of delirium involves environmental
measures as well as treatment of the underlying
cause
• Pharmacological treatment with sedatives or
antipsychotic medication is a last resort
3. Delirium, or acute confussional state, is a
common condition in
older people.
It frequently goes unrecognized and is
often poorly managed. Patients who
develop delirium have increased mortality,
length of stay, complication and
institutionalization rates
compared to non-delirious patients,
independent of other factors. In up to one-
third of cases, delirium can be prevented.
4. A etiology
The a etiology of delirium is not fully
understood.
A genetic predisposition is possible.
Inflammatory mediators may play a part.
There is widespread cortical involvement in
delirium
reflected in the wide range of symptoms,
disturbances of conscious level
sleep wake cycle
with illusions
and
hallucinations.
5. Diagnosis
Delirium is particularly common in
the post-operative period
43–61% after hip fracture
and
higher in intensive care
It is also prevalent in the
emergency department, affecting
one in seven older patients.
It is an acute condition
with symptoms developing over
6. predisposing factors
▪ Old age
▪ Severe illness
▪ Dementia
▪ Physical frailty
▪ Admission with infection
dehydration
7. Precipitating factors
▪ Immobility
▪ Use of physical restraint
▪ Use of urinary catheter
▪ Iatrogenic events e.g. general
anesthesia
▪ Malnutrition
8. People with delirium appear
disorientated and are unable to
focus their attention.
Conversations are difficult to
follow.
Fluctuation in symptoms occurs,
often with a diurnal pattern (i.e.
worse at night),
and
lucid or symptom-free intervals
may occur.
9. A diagnosis of delirium can be
made when all four of the
following features are present.
1 Acute onset.
2 Disturbance of consciousness.
3 Impaired cognition or perceptual
disturbance, not due to
pre-existing dementia.
4 Clinical evidence of an acute
general medical condition,
intoxication or substance
withdrawal
10. two main patterns of delirium:
• hyperactive delirium (agitated and
wandering)
• hypoactive delirium (quiet and
withdrawn).
11. two main patterns of delirium:
• hyperactive delirium (agitated and
wandering)
• hypoactive delirium (quiet and
withdrawn).
Some patients may have features of
both. The hypoactive pattern is
particularly important because it
often goes unrecognized.
12. Diagnostic criteria for delirium
Symptoms are present in the
following areas:
1 Disturbance of consciousness
Reduced clarity of awareness of the
environment
Global disturbance of cognition
2 Perceptual distortions
3 Psychomotor disturbance
Hyper- or hypoactivity and unpredictable
shift from one to the
Other
4 Disturbance of the sleep–wake cycle
5- Emotional disturbance
• Depression
• Anxiety
13. The differential diagnosis of
delirium includes:
• dementia
• depression
• hysteria
• mania
• schizophrenia
• dysphasia
• seizures (temporal lobe seizure or
non-convulsive status
epilepticus).
The most important aspect of
diagnosis in delirium is to get a full
history from someone who knows
the patient
14. The Abbreviated Mental Test
1 How old are you?
2 When is your birthday?
3 What time is it? (to the nearest hour)4
Can you remember this address? 42 West
Street
5 What year is it?
6 What place is this?
7 What is my job? What is that person’s
job? (Recognizing two
people)
8 Can you tell me the year World War One
started or finished?
9 What is the name of the Monarch?
10 Can you count backwards from 20–1?
15. This is a validated test; therefore
asking any 10 of your own
questions is not necessarily valid or
reliable. Half-marks are not
acceptable. A score of 8 or more is
normal
16. Management of delirium
Prevention
Those at high risk for developing
delirium can be targeted for
proactive care aimed at preventing
it. Some risk factors but many in the list of precipitating
factors can be. Other factors,
including environmental ones, are
also important in the prevention
(and management) of delirium, and
are listed
17. Detection
Half of all cases of delirium go
unrecognized. Detection is more
likely in those with difficult behaviors.
Routine cognitive testing will not in
itself identify delirium, but will alert
the clinician to the presence of
cognitive impairment and trigger
further questions to differentiate
delirium from dementia
18. The Confusion Assessment Method
(CAM) is designed to be used
by any clinician
Confusion Assessment Method (CAM)
To have a positive CAM, the patient must
display:
1 The presence of acute onset and fluctuating
course and
2 Inattention (e.g. counting from 20 to 1, with
reduced ability to
maintain or shift attention)
and either
3 (a) Disorganized thinking (disorganized or
incoherent speech)
or
(b) Altered level of consciousness (lethargic
or stuporous)
19. Common drug groups that can cause
delirium in older
people
• Opioid analgesics
• Drugs with anticholinergic
properties
• Sedating drugs e.g.
benzodiazepines
• Corticosteroids
20.
21. Determining the underlying cause
When delirium has been detected, an assessment to
look for the underlying cause is the next step. Several
different acute illnesses, as well as medication, can
produce delirium in at-risk patients have at least two causes. Common causes
of delirium are:
• infection (especially urine, chest and
biliary)
• acute hypoxemia
• electrolyte imbalance
• prescribed medicines
• myocardial infarction (which may be
painless)
• alcohol or benzodiazepine withdrawal
• urinary retention
• fecal impaction
• neurological – stroke, subdural
hematoma, seizures
• post-operative cognitive dysfunction
23. Treatment
People with delirium should be
admitted to hospital, in order to
facilitate observation
investigation and treatment.
Treatment in
delirium has four components:
1 treatment of the underlying
cause(s)
2 environmental measures
3 pharmacological measures
4 prevention of complications
