Delirium is an acute confusional state characterised by an alteration of consciousness with reduced

ability to focus, sustain or shift attention. This leads to congnitive or perceptual disturbances that is
not better accounted for by an already established or evolving dementia. It can also be considered to
be a specific type of confusional state characterised by hyper-vigilance, psychomotor and autonomic
overactivity and manifests as agitation, tremulousness and hallucinations. It can also be
characterised by somnolence and decreased arousal aka hypoactive delirium.

It usually develops over a short period of time (hrs to days) and tends to fluctuate during the course
of the day

DSM-V criteria

 Disturbance in attention – reduced ability to direct, focus, sustain and shift attention and
awareness
 The disturbance develops over a short period of time represents a change from baseline and
tends to fluctuate during the course of the day
 An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial
ability, or perception)
 The disturbance is not better explained by another pre-existing, evolving or established
neurocognitive disorder and do not occur in the context of a severely reduced level of arousal
e.g. coma
 There is evidence from the hx, exam or Ix that the disturbance is caused by a medical condition,
substance intoxication or withdrawal or side effect


Causes

 Medical conditions
 Intoxication
 Medication


Risk factors


Prevention
 Primary prevention
  Non-pharmacologic multi-component approaches targeted at high risk individuals that aims
to reduce and manage the modifiable risk factors
 Examples of interventions designed to mitigate risk factors for delirium
 Orientation protocol – have clocks, calendars, windown with outside view, verbal re-
orienting patients can mitigate confusion that is due to the unfamiliar environment
 Cognitive stimulants – have regular visits from friends and famity. AVOID sensory
overstimulation at night. Useful for those with cognitive impariments
 Physiological sleep – avoid medical procedures and the administration of
medications during sleeping hours. Avoid night time noise
 Early mobilisation and minimised use of restraints
 Visual and hearing aids for patients with impairments
 Avoiding/monitoring the use of problematic medications
 Benzo should be avoided in high risk individuals
 Opioids, dihydropyridines and antihistamines should be used in caution
 Avoiding and treating medical complications
 Dehydration
 Hypoxaemia
 Infections
 Manage pain
 Use non-opioids
 Pharmacologic interventions – the evidence does not support the use of medications to
prevent delirium in the acute care or ICU or post-operative care settings.
 Examples of medications with potential benefits
 Cholinesterase inhibitors e.g. rivastigmine, donepezil
 Anti-psychotics
 Gabapentin
 Melatonin
 Analgesics
 The principles of prevention and therapy
 Avoid factors known to aggravate or cause delirium
 Poly-pharmacy
 Dehydration
 Immobilisation
 Sensory impairment
 Sleep disturbance
 Identify and treat the underlying cause/illness
 Support and restorative care to prevent further decline
 Use low dose short acting agents (pharm) to control dangerous and disruptive behaviours

Mx
 The two pathways are followed simulataneously – one to mangae the behaviour and the other
to determine the underlying cause
 Note that the sx can have a prolonged duration into the post-acute phase after the
underlying cause and risk factors have been corrected
 Treatment of the underlying condition
 Virtually any medical condition can cause delirium. Once the offending cause is identified,
specific therapy against it is directed
 Common causes include
 Metabolic encephalopathy
 Fluid and electrolyte disturbances
 Dehydration
 Hyponatremia or Hypernatremia
 Hypocalcaemia or Hypercalcaemia
 Infections
 Sepsis
 UTI
 RTI
 Skin
 Soft tissue
 Organ failure
 Uraemia
 Liver failure
 Hypoxaemia
 Hypercarbia
 Hypoglycaemia
 Drug toxicity
 They can even occur in therapeutic levels e.g. Lithium or digoxin


  Withdrawal from alcohol and sedatives
 Many older hospitalised patients have thiamine deficiency
 Supportive medical care
 Early identification, management and prevent complications e.g. immobility, aspiration etc
 Hydration
 Nutrition
 Mobility
 Pain management
 Preventing skin breakdowns
 Ameliorating incontinence
 Minimising the risk of aspiration pneumonitis
 Assess care provider suitability
 Management of agitation or disruptive behaviour
 This is less common in older pts and when it occurs, it usually alternates with periods of
hypoactive delirium
 There is a risk of wandering off, falls, removing IV lines and tubes etc
 Sx control is occasionally needed to prevent harm or to alow evaluation and treatment
 Trial psychotropic medications
 Non-pharmacological interventions
 Interpersonal and environmental manifpulations
 Freque3nt reassurances, touch and verbal orientation can lessen disruptive behaviours
 Family members or other familiar people preferred
 Use restraints only as last resort
 Neuroleptic medications
 This is used to treat agitation in the patient with delirium – haloperidol reduces the
severity and duration but not the incidence of it
 Risperidone
 Chlorpromazine
 Haloperidol is more used due to the longer clinical experience. Respiridone, quetiapine,
olanzapine, ziprasidone have fewer side effects and so they can probably do the same
 thing. There is greater extrapyramidal effects in patients given high dose haloperidol,
but were similar in low dose
 Note that Haloperidole is associated with sedation and hypotension and should be
avoided in patients with parkinsonism  use atypical antipsychotics instead
 DOSE: 0.5-1mg Haloperidole max 5mg/day; time to onset 30-60min. IV can lead to QT
prolongation
 Benzodiazepine
 They are indicated when sedative drug or EtOH withdrawl or when neuropleptics are
contra-indicated
 Lorazepam 0.-1mg
 While thy have faster onset, they can cause worsen confusion and sedation
 Cholinesterase inhibitors
 NO
 Management of Pain
 Usually post-operative or post-truma
 Analgesia should be provided
 NOTE: they can also lead to delirium
 Morphine 5mg IM
 Hypoactive delirium
 Sx treatment not done
 ??haloperidol
 s
 x
