Delirium Assessment & Management

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Delirium\: acute, transient, reversible confusion; often due to infection, drugs, dehydration; a
wards.
Types\: hyperactive (agitation, delusions, hallucinations, wandering, aggression) and hypoactive (lethargy, slow tasks,
excessive sleeping, inattention).
Aetiology\: often multifactorial; consider CHIMPS PHONED\: constipation, hypoxia, infection, metabolic disturbance, pain,
sleeplessness, prescriptions, hypothermia/pyrexia, organ dysfunction, nutrition, environmental changes, drugs.
Assessment\: comprehensive history (patient, collateral), cognitive assessment (AMTS, MMSE, ACE-III), clinical examination
(vital signs, consciousness, infection signs).
Confusion screen\: blood tests (FBC, U&Es, LFTs, coagulation, TFTs, calcium, B12, folate, glucose, blood cultures), urinalysis,
imaging (CT head, chest X-ray).
Management\: identify and treat underlying cause; supportive strategies (consistent care, re-orientation, use of aids, enable
independence).
Environmental strategies\: clocks, familiar objects, family involvement, noise control, adequate lighting and temperature.
Medication\: avoid unnecessary meds; sedation (haloperidol, lorazepam) only if necessary; start with low doses.
Post-discharge\: inform family/carers about possible persistence; provide management information; recommend follow-
up.
Prevention\: avoid precipitating drugs, monitor high-risk patients, address factors like pain control, use
supportive/environmental approaches for all patients.
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A comprehensive topic overview
Delirium is an acute, transient and reversible state of confusion, usually the result of other organic processes (infection,
drugs, dehydration), the onset is acute and the cognition of the patient can be highly
One in
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Clinical features

There are two main states of delirium, known as 'hyperactive' and 'hypoactive' delirium.
It is common for patients to
Hyperactive delirium
Hyperactive delirium is the 'typical' delirium presentation that most people are aware of.
Clinical features of hyperactive delirium include\:
Agitation
Delusions
Hallucinations
Wandering
AggressionHypoactive delirium
Hypoactive delirium is less well known and as a result, often missed or confused with depression.
Clinical features of hypoactive delirium include\:
Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention

Aetiology and risk factors

A change in environment coupled with sensory impairment (common in the elderly) increases the risk of developing
delirium. These factors alone can cause delirium without any deeper organic cause, but this should only be considered as a
diagnosis of exclusion.
Things that can cause or lead to delirium include pretty much anything, ever. Some of the biggies are listed below. I'm
generally not a fan of acronyms for the sake of acronyms, but CHIMPS PHONED is a useful reminder that it is not just our
old friend 'UTI' that should be considered\:
Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic or renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)

Assessment of the confused patient

It is essential to perform a comprehensive assessment of all patients suspected of having delirium, given the wide range
of possible causes and varying clinical features.
History
Taking a history directly from the patient may not be possible in the context of acute confusion (although you should
always try)\:
Conversation can give big clues to the patient's current mental state
Provide reassurance and gentle re-orientation if appropriate
Ask the patient what they are seeing/hearing/experiencing
Other useful sources of information include\:
Collateral history (e.g. family, friends, nursing sta
Medical notes (e.g. past medical history, current medications)
Useful information in the patient's medical notes may include\:
Past medical history (e.g. atherosclerosis, stroke, previous episodes of confusion, head injury, recent admissions)
Current medications\: review for drugs that may cause or contribute to confusion (e.g. opiates)
Social history (e.g. how are they coping at home, excess alcohol, illicit drug use)Cognitive assessment
The Abbreviated Mental Test Score (AMTS) is a useful screening tool for assessing cognition.
This tool can be used to objectively monitor for improvement or deterioration in cognitive function over time.
Other cognitive screening tools which provide more detailed assessment include MMSE and ACE-III.
Clinical examination
A thorough clinical examination (including assessment of vital signs) should be performed, looking for signs which may
provide clues as to the underlying cause of confusion\:
Vital signs (e.g. fever in infection, low SpO 2
Level of consciousness (e.g. GCS/AVPU)
Evidence of head trauma
in pneumonia)
Sources of infection (e.g. suprapubic tenderness in urinary tract infection)
Asterixis (e.g. uraemia/encephalopathy)
Confusion screen
When investigating why a patient might be confused, there are a standard set of further investigations which are often
referred to as a 'confusion screen'
. This panel of investigations is useful for identifying or ruling out common causes of
confusion.
Blood tests\:
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate de
Glucose (e.g. hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
Urinalysis\:
UTI is a very common cause of delirium in the elderly.
A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of
delirium.
2, 3
Look for other evidence supporting the diagnosis (WCC↑/supra-pubic tenderness/dysuria/o
urine culture).
Imaging\:
CT head\: if there is concern about intracranial pathology (bleeding, ischaemic stroke, abscess)
Chest X-ray\: may be performed if there is concern about lung pathology (e.g. pneumonia, pulmonary oedema)

Management of delirium

De
De
Supportive management strategies
General supportive management strategies include\:
Try to keep a consistent nursing and medical team, gentle re-orientation, calm and consistent care, regular introductions
of yourself and your role, clear and concise communication.
Ensure the patient has access to aids such as glasses, hearing aids and walking sticks where appropriate.Enable the patient to do what they can for themselves - independent washing, dressing, eating, toileting and other
activities may still be possible with varying levels of encouragement.
Environmental adaptation management strategies include\:
Ensure there is access to a clock and other orientation reminders for the day, date and time.
Have some familiar objects where possible (e.g. having photographs available, using the patient's own
clothes/washcloths).
Involve the family, friends and/or carers in the care of the patient.
Control the level of noise around the patient.
Ensure lighting is adequate and the temperature is ambient.
Medication
Key points include\:
Avoid unnecessary medications wherever possible.
Persistent wandering and delirium are not absolute indications for sedation.
Aim to keep the patient safe by the least restrictive method.
The use of medications, particularly those for sedation, can worsen delirium.
Haloperidol (oral, IV or IM) is usually the
If benzodiazepines are to be used, lorazepam is
(see the NICE guidance for further management).
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Post-discharge
Key points include\:
Families/carers need to be aware that delirium can continue for a period of time after the cause has been treated
Information should be given to those surrounding the patient on the management of any residual disorientation or
inattention
Follow-up is advisable
Prevention
Take appropriate steps to prevent episodes of delirium\:
Avoid drugs known to precipitate delirium (e.g. opiates and benzodiazepines)
Identify patients at higher risk of developing delirium and observe them closely for early signs of delirium
Assess other factors which may induce or exacerbate delirium (e.g. pain control, drugs etc)
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Employ supportive/environmental management approaches for all patients, regardless of delirium risk

References

Oxford Handbook of Clinical Medicine, 8th Ed, p488
Beveridge, Davey, Phillips, McMurdo (2011), Optimal Management of Urinary Tract Infections in Older People, Clin Interv
Aging. 2011; 6\: 173–180. Available from\: [LINK]
Woodford, George (2009) Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People, J Am Geriatr
Soc. 2009 Jan;57(1)\:107-14. Available from\: [LINK]
McMurdo, Gillespie (2000) Urinary tract infection in old age\: over-diagnosed and over-treated. Age & Ageing (2000)29
(4)\:297-298
SIGN (2012), 88\: Management of Suspected Bacterial Urinary Tract Infection in Adults\: A Clinical Guideline. Available from\:
[LINK]
Delirium, NICE Clinical Guideline (July 2010). Available from\: [LINK]Related notes
Postural Hypotension in Older Adults
Source\: geekymedics.com