Makindo Medical Notes

Related Subjects: |Coma management

Introduction

Delirium is an acute clinical syndrome characterized by fluctuating consciousness, inattention, and cognitive impairment. Often temporary, it is also referred to as an acute confusional state. Prevention and management strategies focus on holistic care practices to improve patient outcomes significantly.

Importance of Delirium

• Delirium can be distressing to patients and families, often signaling reduced cognitive reserve overwhelmed by underlying causes.
• It is associated with higher long-term morbidity and mortality rates.
• Delirium increases the risk of falls, infections, immobility, and longer hospital stays.

Prevalence

• 10% of all medical admissions involve delirium.
• Rates increase to 20-30% on medical wards and 70-87% in ICU settings.

Risk Factors

• Age > 65, male gender, depression
• History of stroke, severe illness, cognitive impairment/dementia
• Visual or auditory impairments, malnutrition, smoking, catheter usage
• Multiple new medications, prolonged hospital stays, environmental disorientation (e.g., wards without windows)

Clinical Presentation

• Cognitive function: Worsened concentration, slow responses, confusion
• Perception: Visual or auditory hallucinations
• Physical function: Reduced mobility, restlessness, agitation, changes in appetite, sleep disturbance
• Social behaviour: Lack of cooperation, withdrawal, altered communication, mood changes

Diagnosis: Confusion Assessment Method (CAM)

• Criteria for diagnosing delirium include:
• Acute onset and fluctuating course AND inattention
• Plus either disorganized thought processes OR altered level of consciousness

Consequences of Delirium

• Prolonged hospital stays, on average 8 days longer.
• Increased in-hospital mortality (up to 75%) and post-discharge mortality (40% 1-year mortality).
• Higher risk of hospital-acquired infections, pressure ulcers, incontinence, and falls.
• Poor cognitive and physical recovery, with lower scores on cognitive assessments at discharge.
• Increased risk of needing residential care and developing dementia, even in those previously without cognitive impairment.

Key Features of Delirium

• Essential Features:
• Acute onset with fluctuating course
• Inattention, disorganized thinking, cognitive impairment
• Variable Features:
• Perceptual disturbance, emotional disturbance, hyper/hypoactive states, altered sleep/wake cycle

Prevention

• Provide appropriate lighting, clear signage, a clock, and a calendar for orientation.
• Reorient patients by explaining where they are, who you are, and your role in their care.
• Introduce cognitively stimulating activities (e.g., reminiscence therapy).
• Encourage regular visits from family and friends.
• Maintain hydration and assess for hypoxia, managing oxygen saturation as appropriate.
• Avoid unnecessary catheterization and promote mobility and range-of-motion exercises.
• Review medications and ensure adequate nutrition and sensory aids (e.g., glasses, hearing aids).

Common Causes and Aggravating Factors

• Dehydration: Poor fluid intake, high glucose, calcium imbalance
• Drugs: CNS depressants, opiates, anticholinergics
• Environment: Hospitalization, unfamiliar surroundings, loss of familiar cues
• Electrolyte disturbance: Hyponatremia (sodium < 120 mmol/L)
• Infection: Especially chest and urinary infections
• Immobility: Sarcopenia, prolonged bed rest
• Respiratory failure: Hypoxia, hypercarbia
• Other factors: Urinary retention, constipation, pain, and discomfort

Focused Investigations

• Initial tests: Pulse oximetry, NEWS score, ABG if needed
• Lab work: FBC, U&E, CRP, TFT, calcium, magnesium, B12, folate
• Additional: ECG, CXR, CT head, urinalysis, blood cultures
• Second line: LP, CT CAP, LDH, PSA, MRI for encephalitis if necessary

Management

• Ensure management of hypoxia, infections, and electrolyte imbalances.
• Optimize the environment for sleep, nutrition, and family involvement.
• Rationalize medications and avoid unnecessary use of sedatives or antipsychotics, particularly in patients with Parkinson’s or Lewy body dementia.
• Encourage supportive care such as reorienting the patient and providing emotional reassurance.

Drugs for Sedation

• Haloperidol: 0.5 mg PO/IM every 1-2 hours as needed, up to a maximum of 5 mg/day.
• Lorazepam: 0.5-1 mg PO/IM, up to 4 mg/day, especially useful in patients with prolonged QT interval or Parkinson’s/Lewy body dementia.

References

• Delirium: Prevention, Diagnosis, and Management (NICE)
• Review Article on Delirium