What is the definition of delerium?
A syndrome of acute, fluctuating change in mental status, with inattention, disorganised thinking, and altered levels of consciousness. It is a potentially life-threatening disorder characterised by high morbidity and mortality.
What is the general prevalence of delerium in the in-patient population?
What is important to remeber about confusion in terms of its association with a delerium?
It is a symptom of muddled thinking, which is not confined solely to delerium, and can be present in depression, dementia and psychotic disorders.
It is presentation, not a diagnosis
What are the features of delerium?
Disordered thinking - slow irrational rambling, jumbled up, incoherent ideas
Euphoric/fearful/depressed/angry - labile mood, anxious then torpid
Language impairment - speech reduced or gabbling, repetitive, disruptive
Illusions/delusions/hallucinations - tactile or visual (auditory suggests psychosis)
- Reversal circadian rhythm
Inattention - focusing is poor, no real dialogue
Unaware/disorientated - doesn't know own name, or location
- Memory deficits
What are the features hyperactive delerium?
- Oversensitive to stimuli
- Psychomotor stimulation
What are the 3 key features of delerium?
Change in cognition
- Acute onset and fluctuant
What can cause delerium?
- Drug intoxication
Disorders of electrolyte/fluid balance - dehydration, uraemia
- Alcohol/drug withdrawal
Organ failure - cardiac, respiratory, liver
Intracranial pathology- stroke, tumour, bleed
- Constipation/urinary retention
What medications can cause delerium?
- Anxiolytics - barbituates, benzodiazepines
- H2 receptor blockers
What recreational drugs can cause delerium?
How would you approach assessing a patient with delerium?
- Collateral History
What is the 4AT?
Rapid assessment for delerium which includes the month backwards test and the abbreviated mental test 4.
It is used to asses for moderte to severe cognitive impairment, and for delerium
What investigations would you do if someone presented with delerium?
Based on TIME bundle
- Bloods - FBC, ESR, TFTs, U+Es, Glucose, CRP, Calcium and phosphate
- Urinalysis + culture
- Blood cultures
- Blood gases
What tests would you do to asses for infection as a cause for delerium?
- Bloods - FBC, ESR, CRP
- Blood culture
- Urinalysis and culture
How would you assess for dehydration as a cause of delerium?
Bloods - U+Es
What is a TIME Bundle?
A tool used for guiding assessment and management of someone with delerium
How would you assess abnormal blood sugar as a cause of delerium?
Finger prick blood test
Bloods - Glucose
How would you assess hypoxaemia or hypercapnia as contributory causes of delerium?
What non-pharmacological measures would you use to manage someone with delerium?
- Re-orientate and reassure agitated patients - USE FAMILIES/CARERS
- Encourage early mobility and self-care
- Correction of sensory impairment
- Normalise sleep-wake cycle
- Ensure continuity of care
- Avoid urinary catheterisation/venflons
When would pharmacological measures be used to manage someone with delerium?
If the patient becomes agitated leading them to become a danger to themselves or others, or to interfere with medical treatement (e.g. cannulas)
What medications could you use for an agitated delerious patient?
Single drug or combination of:
- Short-acting benzodiazepines - lorazepam
- Typical antipsychotics - haloperidol
- Atypical antipsychotics - olanzapine, risperidone, quitiepine
What should you remember when administering medications to an agitated delerious patient?
Start low and go slow, and use for as short a period as possible
Who are most at risk of developing delerium?
- Old individuals taking multiple medicines
- Surgical patients - esp hip
- Poor sight and hearing
- Urinary retention
What is important to remember about delerium in terms of the cause?
It is often because of multiple precipitants
What are features of hypoactive delerium?
- Psychomotor retrdation
- Paucity of speech
- Few hallucinations
What is the defintion of capacity?
Ability to understand information relevant to a decision or action and to appreciate the reasonably forseeable consequences of taking or not taking that action or decison
What are the steps to assesing capacity?
- Presume capacity - always assume unless there is evidence to the contrary
- Maximise capacity - if lacking capcaity
- Bad decisions not necessarily incapable
- Mental disorder or severe communication disorder
What classes of mental disorders can lack capacity?
- Sensory impairment
What are the 5 aspects of decision making that need to be present in order for someone to be deemed to have capacity?
- Making decision
- Understanding decisions
- Communicating decisions
- Retaining memory of decisions
What is power of attorney?
Power granted by person (when they have the capacity to do so) to make sure that their future decisions are safeguarded, even when they lode the ability to make these decisions themselves
What are the different types of power of attorney?
- Continuing - financial only
- Welfare - decisions about health and wellbeing
- Combined - both financial and decisions
What is guardianship?
Legal authority for someone to make decisions and act on behalf of a person who has lost capacity to make certain decisions.
May cover money, property, welfare and health
What mnemonic could you use to remember causes of delerium?