QuestionSBA
QuestionChoice
De-escalation has already been tried and failed in this case. It is reasonable to also take more restrictive measures i.e. pharmacological intervention.
61971
d
De-escalation techniques
QuestionChoice
Phenobarbital is a long-acting sedative-hypnotic anti-epileptic agent that is not recommended. Haloperidol would usually be first-line treatment but Lewy Body Dementia (and Parkinson's disease) contraindicate its use. Other notable contraindications include recent myocardial infarction, long QTc, hypokalaemia, and decompensated heart failure.
61969
b
Phenobarbital
QuestionChoice
While bloods may be useful for identifying underlying causes of his delirium, it would be practically dangerous if the patient is resisting intervention and not useful in the acute setting where rapid de-escalation or sedation is  needed in the first instance.
61972
e
Take some blood tests
QuestionChoice
Lorazepam is a reasonable first-choice benzodiazepine for sedation in this case as it is rapid onset and short acting. Haloperidol would usually be first-line treatment but Lewy Body Dementia (and Parkinson's Disease) contraindicate its use. Other notable contraindications include recent myocardial infarction, long QTc, hypokalaemia, and decompensated heart failure.
61968
a
Lorazepam
QuestionChoice
Diazepam is a long-acting benzodiazepine; a short-acting agent like lorazepam would be preferable to minimise restraint and adverse effects. Haloperidol would usually be first-line treatment but Lewy Body Dementia (and Parkinson's disease) contraindicate its use. Other notable contraindications include recent myocardial infarction, long QTc, hypokalaemia, and decompensated heart failure.
61970
c
Diazepam
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/).
896
2442
Delirium
Topic
57
Geriatrics
12455
A 68 year old male is becoming increasingly aggressive and agitated on the ward. He is confused and lashing out at staff members despite several attempts at de-escalation. He has acute pneumonia, a past medical history of metastatic rectal cancer and Lewy Body Dementia.

Which of the following is the best next step in the management of this patient?
a