QuestionSBA
QuestionChoice
Lithium is commonly used to treat bipolar disorder. There is a high chance of developing delirium following exposure to it. Therefore, it is avoided.
62022
e
Lithium
QuestionChoice
Trimipramine is a tricyclic antidepressant medication that is commonly used to treat depression. It is avoided due to the fear of drug-induced delirium.
62020
c
Trimipramine
QuestionChoice
Nortriptyline is commonly used to treat depression, anxiety, and chronic pain. Tricyclic antidepressants are avoided as they cause drug-induced delirium.
62021
d
Nortriptyline
QuestionChoice
Risperidone is an atypical antipsychotic medication that is commonly used to treat a wide range of psychiatric disorders, including psychosis, bipolar disorder, and schizophrenia.
62019
b
Risperidone
QuestionChoice
Delirium is an acute confusional state characterised by severe changes in behaviour and cognition. It is often triggered by an illness, medication, or withdrawal from a substance. Patients with delirium may present with visual hallucinations, delusions, and frank psychosis. The lowest possible dose of olanzapine or haloperidol is preferred if supportive management fails.
62018
a
Olanzapine
QuestionComment
why olanzapine and not risperideone?
26333
QuestionComment
Hello, I did some quick searching and found that olanzapine has a faster onset of action compared to Risperidone. In addition, Risperidone also has higher incidence of extra-pyramidal side effects and should be used with caution in elderly patients.  Happy to be corrected if anyone else has any further information
27280
User
subscriber
Ketone Outpatient
User
subscriber
Sir Pep Guardiola
QuestionComment
Why not haloperidol?
28699
QuestionComment
because its not an option in the question
45071
User
subscriber
Axillary Monoclonal
User
subscriber
Ketone Dorsal
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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Delirium
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Geriatrics
12465
A 78-year-old woman in long-term residential care has recently become confused, disoriented and hallucinating following a chest infection. She has already been prescribed antibiotics for the chest infection, which she started taking a day ago. The staff are concerned that she is a risk to herself. They have attempted verbal and non-verbal de-escalation techniques; however, she continues to be agitated and restless.

What is the single most appropriate short-term medication?
a