Delirium - Coggle Diagram
History of, or current, alcohol excess
Lack of stimulation
Terminal phase of illness
Correct any precipitating factors
Optimize treatment of comorbidities
If admission is not appropriate, seek advice from an elderly care consultant or psychiatrist when: is doubt about the diagnosis, severe delirium, Detention under the Mental Health Act (1983, amended 2007) is being considered, further investigations are not available in primary care or the person does not respond to initial treatment in primary care.
Give advise to family/carers to provide explanations for activities in a calm manner, try reorientation strategies, maintain safe mobility, normalize the sleep-wake cycle.
Management in primary care may be appropriate if all of the following are present: The benefits of management in primary care outweigh the benefits of hospital admission, or the person is clinically well enough to stay at home; The symptoms of delirium are not harmful to the person or others, and can be managed safely in primary care; The cause of delirium is known and treatable; The person can receive constant supervision and care from a healthcare professional trained in the management of delirium — to minimize complications; Close clinical follow up can be arranged.
If challenging behaviour develops such as aggression, agitation or shouting address underlying cause, advise moving the person to a safe, low stimulating environment, use of verbal and non-verbal de-escalation techniques and if these fail seek further advise.
The decision as to whether to admit or refer a person with delirium to secondary care depends on the person's specific clinical and social situation, and should also take into account the views of family members or carers.
If the person with delirium is in the palliative phase of an illness, other measures may be suggested.
Most people with delirium should be admitted to hospital for urgent assessment, close monitoring, and treatment.
Arrange follow up
Give explanation of diagnosis
Altered cognitive function
Behaviour change which develops acutely including:
Altered physical function
Altered level of consciousness
Altered social behaviour
Falling and loss of appetite are often warning signs for delirium
Any precipitating factors
Examination: vital signs, general examination for precipitating factors respiratory, cardiovascular, abdominal, MSK, Neurological, skin, electrolyte imbalance, endocrine and metabolic, sensory impairment and pain.
Social circumstances and any care packages
Confirm diagnosis by carrying out cognitive assessment - DSM-5 criteria.
Baseline functional and cognitive state
Most people with delirium will need admission for same-day investigation and treatment of precipitating factors. If admission is not appropriate, arrange targeted investigations based on findings from the history and examination.
Onset, nature, course of the behaviour change
Investigations - Consider - urinalysis, sputum culture, FBC, Foltae and B12, U&E, HbA1c, Calcium, LFTs, Inflammatory markers, Drug levels, TFTs, Chest x-ray and ECG.
Non-convulsive epilepsy or temporal lobe epilespy
Charles Bonnet syndrome
Definition: Delirium is an acute, fluctuating syndrome of encephalopathy causing disturbed consciousness, attention, cognition, and perception. Delirium usually develops over hours to days and behavioural disturbance, personality changes, and psychotic features may occur. Delirium typically occurs in people with predisposing factors (such as advanced age or multiple comorbidities) when new precipitating factors (such as some medications or infection) are added. Delirium can be classified into hyperactive, hypoactive or mixed. Precipitating factors include infection, metabolic disturbance, etc.