Delirium

Acute and fluctuating disturbance in attention and awareness

Need to differentiate from Dementias

	Delirium	Dementia
Onset	Acute	Insidious
Course	Fluctuating	Progressive
Duration	Days to weeks	Months to years
Consciousness	Impaired	Usually alert
Attention	Impaired	Normal and then impaired
Psychomotor changes	Increased or decreased	Often normal
Hallucinations	Common	Less common (type dependant)
Reversibility	Usually reversible	Progressive

Collateral history may be very useful - if patient has capacity patient needs to consent for the collateral history to be taken. Assessment of capacity is important

Types

• Hyperactive delirium - predominantly restless and agitated. Often occurs during night time
• Hypoactive delirium - inactive and sleepy. During the day often

Causes/Factors

Pain Infection - Urinary Tract Infection, pneumonia, Cellulitis, Skin Ulcers Nutrition - B12, folate, glucose, Nutritional disorders Constipation - +/- urinary retention, codiene Hydration - intake, diruetics, diarrhoea

Medication - prescribed, alcohol and drugs, withdrawal Environment/electrolytes

Symptoms

• Disturbed Consciousness: Reduced clarity, orientation, and awareness.
• Cognitive Dysfunction: Impaired memory, disorientation, and confusion.
• Fluctuating Alertness: Symptoms vary throughout the day.

Signs

• Inattention: Difficulty focusing or sustaining attention.
• Altered Perception: Hallucinations or misinterpretation of stimuli.
• Disorganized Thinking: Incoherent speech, illogical thoughts.

Social History

• Who do they live with?
• Alchol, drugs, work
• House - stairs?
• Daily tasks of living - wash, dress
• Shopping?

Investigations

• Observations: full set of obs, ECG, urine dip, glucose

• Cognitive Assessment:

  • 4AT - Alertness, Cognition, Attention, Acute changes or fluctuating course
  • MoCA -

• Blood Tests: FBC, U&Es, TFTs, LFTs, HbA1C, Coag screen, Bone profile, Folate & B12, vitamin D

• Imaging: CXR for pneumonia, CT head to rule out bleeds, bladder USS

Management

• Address Underlying Cause: Treat the root medical condition or discontinue offending medications.
• Environmental Support: Maintain a quiet, well-lit environment to reduce confusion.
• Challenging Behaviour: Frustration is natural if you cannot effectively communicate needs. Medication is an option as a last resort after communication tactics have failed.
• Communication: Always try to redirect patients rather than decieve etc.

Complications/Red Flags

• Longer stay in hosptial: more hosptial aquired complications
• Increased Morbidity and Mortality: Delirium is often a sign of severe illness and have a 2x mortality risk than a normal patient
• Risk of Falls and Injuries: Altered mental status poses safety risks.
• Potential for Long-Term Cognitive Impairment: Especially in older adults, delirium can contribute to persistent cognitive decline.