Delirium (sometimes called 'acute confusional state') is an acute, fluctuating syndrome of inattention, impaired level of consciousness, and disturbed cognition.
Classes
Hyperactive delirium can present with inappropriate behaviour, hallucinations, or agitation.
Hypoactive delirium can present with lethargy and reduced concentration and appetite.
Mixed delirium presents with signs and symptoms of both hyperactive and hypoactive subtypes.
Factors
Predisposing
Older age (over 65 years), Cognitive impairment (such as dementia).
Frailty/multiple comorbidities (such as stroke or heart failure).
Significant injuries such as hip fracture.
Functional impairment (for example immobility or the use of physical restraints such as cot sides).
Iatrogenic events (such as bladder catheterization, polypharmacy, or surgery).
History of, or current, alcohol excess.
Sensory impairment (such as visual impairment or hearing loss).
Poor nutrition.
Lack of stimulation.
Terminal phase of illness.
Precipitating
Infection such as urinary tract infection, infected pressure sore, or pneumonia.
Metabolic disturbance such as hypoglycaemia, hyperglycaemia (including advanced carcinomatosis), or electrolyte abnormalities (including that due to dehydration).
Cardiovascular disorders such as myocardial infarction or heart failure.
Respiratory disorders such as pulmonary embolism or exacerbation of chronic obstructive pulmonary disease.
Neurological disorders such as stroke, encephalitis, or subdural haematoma.
Endocrine disorders such as thyroid dysfunction or Cushing's syndrome.
Urological disorders such as urinary retention.
Gastrointestinal disorders such as hepatic failure, constipation (including faecal impaction), or malnutrition.
Severe uncontrolled pain.
Alcohol intoxication or withdrawal.
Medication:
Psychosocial factors e.g depression
Complications
increased mortality.
Increased length of stay in hospital.
Nosocomial infections.
Increased risk of admission to long-term care or re-admission to hospital.
Increased incidence of dementia.
Falls.
Pressure sores.
Continence problems.
Malnutrition.
Functional impairment.
Distress for the person, their family, and/or carers.
Diagnosis
DDx
Management
Physical illness e.g thyroid disease, charles bonnet syndrome, temporal lobe epilepsy
Mental illness e.g. depression, dementia, anxiety
Signs & Symptoms
Behavioural changes- acutely over hours and days, altered cognitive function, inattention, disorganised thinking, altered perception, altered physical function, social behaviour and level of consciousness
Falling and loss of appetite
Hx and baseline function and cognitive state
Identify precipitating factors
Examination
CAM/DSM IV criteria
Hospital admission urgent assessment, close monitoring and treatment
where admission is not apt -arrange targeted investigations based on findings from the history and examination e.g urine, bloods, sputum specimen
Primary care- refer to elderly care consultant/psychiatrist if doubt with diagnosis, severe agitation or distress , detention required