QuestionSBA
QuestionChoice
Whilst this is a good thought, de-escalation should be the initial management of delirium and part of this assessment would be whether pain is a contributing factor. Paracetamol should therefore only be given in certain circumstances rather than as a first line treatment for every delirious patient.
61967
e
Give some paracetamol as he may be in pain
QuestionChoice
It is important to use the least invasive or restrictive management option first. This includes verbal and non-verbal de-escalation techniques to help calm the patient down. This might include validating their distress,  re-orientation, calling in family members, and trying to reduce deliriogenic factors (PINCH ME: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment).
61963
a
De-escalation techniques
QuestionChoice
Sedation is a form of restraint, and carries risk. It should not be administered before trying to de-escalate with communication techniques first. Oral sedation is less invasive than intramuscular and therefore is preferable if possible in the given situation; however, Haloperidol is the NICE recommended pharmacological agent of choice.
61966
d
Lorazepam 500 micrograms PO
QuestionChoice
All sedation is a form of restraint, and carries risk. Sedation can worsen delirium, increase falls risk and have side-effects. It should not be administered before trying non-pharmacological interventions first. Haloperidol is first-line **pharmacological** acute treatment for delirium where a patient poses a risk to themselves or others. It has cardiac and neurological side-effects and is contraindicated in Parkinson's and Lewy Body Dementia.
61964
b
Haloperidol 500 micrograms IM
QuestionChoice
All sedation is a form of restraint, and carries risk. Sedation can worsen delirium, increase falls risk and have side-effects. It should not be administered before trying non-pharmacological interventions first. Lorazepam is a reasonable sedative option but haloperidol is the only agent recommended (with caution) by NICE.
61965
c
Lorazepam 500 micrograms IM
QuestionComment
good trick question

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Uremic Serotonin
Concept
Chapter
# Summary

Delirium, also known as acute confusional state, is a frequent condition, primarily observed among elderly individuals. It manifests through symptoms such as disorientation, hallucinations, inattention, memory problems, mood or personality changes, and disturbed sleep. Comprehensive investigation includes physical examination and infection screen. Management focuses on treating the underlying cause, optimising the patient's environment, and, in severe cases, considering sedative measures.

# Definition

Delirium is an acute and fluctuating disturbance in attention and cognition, often accompanied by a change in consciousness. It is typically reversible and frequently seen in the elderly, particularly in inpatient settings. It manifests in three subtypes:

* **Hyperactive** Delirium: Marked by increased psychomotor activity, restlessness, agitation, and hallucinations.
* **Hypoactive** Delirium: Characterised by lethargy, reduced responsiveness, and withdrawal.
* **Mixed** Delirium: Combines features of both hyperactive and hypoactive delirium.

# Epidemiology

Delirium is a common condition, predominantly affecting elderly people, and is seen in up to 30% of elderly inpatients. The incidence increases with age, severity of illness, and the presence of pre-existing cognitive impairment.

# Aetiology

The causes of delirium can be multifactorial and are remembered using the mnemonic DELIRIUMS:

- D: Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
- E: Eyes, ears and emotional disturbances
- L: Low Output state (Myocardial Infarction, Acute Respiratory Distress Syndrome, Pulmonary Embolism, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease)
- I: Infection
- R: Retention (of urine or stool)
- I: Ictal (related to seizure activity)
- U: Under-hydration/Under-nutrition
- M: Metabolic disorders (Electrolyte imbalance, thyroid disorders, Wernicke's encephalopathy)
- (S): Subdural hematoma, Sleep deprivation

# Signs and Symptoms

Delirium can present in a number of different ways, including:

- Disorientation
- Hallucinations - visual or auditory
- Inattention
- Memory problems
- Change in mood or personality. **Sundowning** is agitation and confusion worsening in the late afternoon or evening.
- Disturbed sleep

Patients may be hypoactive (sedated) or hyperactive (very agitated), and these presentations can fluctuate over time. Hyperactive delirium is easily seen due to the presentation, while hypoactive delirium can be easily missed as patients may appear more withdrawn.

# Differential Diagnosis

Delirium can mimic several other conditions and it's crucial to consider the following in differential diagnosis, each with its key signs and symptoms:

- Dementia: Characterized by gradual onset, stable consciousness level, and progressive decline in cognitive function.
- Psychosis: May present with hallucinations and delusions, but usually with preserved orientation and memory.
- Depression: May exhibit poor concentration and slow cognition, but typically with a stable consciousness level and often accompanied by pervasive feelings of sadness or guilt.
- Stroke: Abrupt onset with focal neurologic signs and specific deficits in speech, motor, or sensory function.
  
# Investigations

- 4AT and CAM are commonly used tools for delirium assessment.

Initial investigations should include a comprehensive physical examination and infection screen. Additional investigations should be guided by clinical suspicion based on the patient's history and physical examination. These may include:

- Bedside - bladder scan, review medications, ECG (arrhythmias, ischaemic changes that could cause hypoperfusion) urine MC&S - you should not perform urine dipstick if >65 as they are less sensitive in this age group.
- Bloods: FBC, urea and electrolyes, liver function tests, thyroid function tests, and blood cultures.
- Imaging:  chest X-ray, or ultrasound of the abdomen. Neuroimaging with CT or MRI head is reserved for those without a clear identifiable cause.


# Management

Management of delirium primarily focuses on treating the underlying cause. Non-pharmacological strategies should be the first line, which include:

- Providing an environment with good lighting
- Maintaining a regular sleep-wake cycle
- Regular orientation and reassurance
- Ensuring the patient's glasses and hearing aids are used if needed

For patients who are extremely agitated and potentially a danger to themselves or others, pharmacological interventions such as small doses of haloperidol or lorazepam. Olanzapine may also be considered however, these should be used with caution, especially in the elderly, due to the risk of side effects. 

# NICE Guidelines

For more information, see [NICE CKS on delirium](https://cks.nice.org.uk/topics/delirium/).
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2442
Delirium
Topic
57
Geriatrics
12454
A 79 year old male with a urinary tract infection on the medical  ward is acutely agitated and confused. He is shouting, disturbing other patients and the ward nurses are struggling to cope. He is pulling out his lines and trying to climb out of bed. He is 70kg and only past medical history is gout.

Which of the following is the most appropriate initial management of this situation?
a