DELIRIUM (ACUTE CONFUSIONAL STATE)
Delirium = a sudden state of severe confusion with rapid changes in brain
function, sometimes associated with hallucinations and hyperactivity.
Risk Factors:
- Age > 65
- Polypharmacy
- Multimorbidity
- Frailty
- Background of dementia
- Significant injury e.g., hip fracture
Causes of Delirium = I WATCH DEATH:
- Infections
- Withdrawal
- Acute metabolic
- Trauma
- CNS pathology
- Hypoxia
- Deficiencies
- Endocrinopathies
- Acute vascular
- Toxins/drugs
- Heavy Metals
Important reversible causes of confusion:
- Thyroid problems (e.g., thyroid storm or myxoedema coma)
- Folate deficiency (test for B12 deficiency before folate treatment as this
must be treated first)
- Hypercalcaemia
, - Alcohol withdrawal (acute e.g., Wernicke’s encephalopathy or chronic
and irreversible e.g., Korsakoff’s)
- Intracranial pathologies e.g., normal pressure hydrocephalus (triad of
gait ataxia, incontinence and confusion), subdural haemorrhage
(fluctuating confusion), or ischaemic stroke
- Rare pathologies e.g., syphilis & CJD
Clinical Features of delirium:
- Memory disturbances (loss of short term > long term)
- Agitated/withdrawn behaviour
- Disorientation
- Mood change
- Visual hallucinations
- Disturbed sleep cycle
- Poor attention
Management:
- Treat underlying cause
- Modify environment
- Haloperidol 0.5mg first-line sedative if conservative management
unsuccessful (olanzapine second line)
- Management can be challenging in patients with co-morbid Parkinson’s
because antipsychotics can worsen parkinsonian symptoms and so a
better approach is to carefully reduce the Parkinson medication, and if
, urgent treatment required then atypical antipsychotics are preferred
(quetiapine and clozapine)
Hypoactive Delirium
Characterised by:
- Reduced motor activity
- Lethargy
- Withdrawal
- Drowsiness
- Staring into space
Hyperactive Delirium
Characterised by:
- Increased motor activity
- Restlessness
- Agitation
- Aggression
- Wandering
- Hyper-alertness
- Hallucinations and delusions
- Inappropriate behaviour
, ATYPICAL DISEASE PRESENTATION & MULTIPLE PATHOLOGY
Electrolyte Imbalance
Hypokalaemia:
K+ and H+ are competitors and so hyperkalaemia tends to be associated with
acidosis because as K+ rises, fewer H+ can enter the cells, leading to more H+ in
the blood = acidosis
- Causes of hypokalaemia with acidosis:
Diarrhoea
Renal tubular acidosis
Acetazolamide
Partially treated DKA
- Causes of hypokalaemia with alkalosis:
Vomiting
Thiazide and loop diuretics
Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
Hyperkalaemia:
- Causes of hyperkalaemia:
1) Conditions e.g., AKI, CKD, rhabdomyolysis, adrenal insufficiency,
tumour lysis syndrome
2) Medications e.g., aldosterone antagonists/K+ sparing diuretics
(spironolactone and eplerenone), ACEi, ARBs, NSAIDs, and potassium
supplements
- ECG Signs:
Tall, tented T waves
Delirium = a sudden state of severe confusion with rapid changes in brain
function, sometimes associated with hallucinations and hyperactivity.
Risk Factors:
- Age > 65
- Polypharmacy
- Multimorbidity
- Frailty
- Background of dementia
- Significant injury e.g., hip fracture
Causes of Delirium = I WATCH DEATH:
- Infections
- Withdrawal
- Acute metabolic
- Trauma
- CNS pathology
- Hypoxia
- Deficiencies
- Endocrinopathies
- Acute vascular
- Toxins/drugs
- Heavy Metals
Important reversible causes of confusion:
- Thyroid problems (e.g., thyroid storm or myxoedema coma)
- Folate deficiency (test for B12 deficiency before folate treatment as this
must be treated first)
- Hypercalcaemia
, - Alcohol withdrawal (acute e.g., Wernicke’s encephalopathy or chronic
and irreversible e.g., Korsakoff’s)
- Intracranial pathologies e.g., normal pressure hydrocephalus (triad of
gait ataxia, incontinence and confusion), subdural haemorrhage
(fluctuating confusion), or ischaemic stroke
- Rare pathologies e.g., syphilis & CJD
Clinical Features of delirium:
- Memory disturbances (loss of short term > long term)
- Agitated/withdrawn behaviour
- Disorientation
- Mood change
- Visual hallucinations
- Disturbed sleep cycle
- Poor attention
Management:
- Treat underlying cause
- Modify environment
- Haloperidol 0.5mg first-line sedative if conservative management
unsuccessful (olanzapine second line)
- Management can be challenging in patients with co-morbid Parkinson’s
because antipsychotics can worsen parkinsonian symptoms and so a
better approach is to carefully reduce the Parkinson medication, and if
, urgent treatment required then atypical antipsychotics are preferred
(quetiapine and clozapine)
Hypoactive Delirium
Characterised by:
- Reduced motor activity
- Lethargy
- Withdrawal
- Drowsiness
- Staring into space
Hyperactive Delirium
Characterised by:
- Increased motor activity
- Restlessness
- Agitation
- Aggression
- Wandering
- Hyper-alertness
- Hallucinations and delusions
- Inappropriate behaviour
, ATYPICAL DISEASE PRESENTATION & MULTIPLE PATHOLOGY
Electrolyte Imbalance
Hypokalaemia:
K+ and H+ are competitors and so hyperkalaemia tends to be associated with
acidosis because as K+ rises, fewer H+ can enter the cells, leading to more H+ in
the blood = acidosis
- Causes of hypokalaemia with acidosis:
Diarrhoea
Renal tubular acidosis
Acetazolamide
Partially treated DKA
- Causes of hypokalaemia with alkalosis:
Vomiting
Thiazide and loop diuretics
Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
Hyperkalaemia:
- Causes of hyperkalaemia:
1) Conditions e.g., AKI, CKD, rhabdomyolysis, adrenal insufficiency,
tumour lysis syndrome
2) Medications e.g., aldosterone antagonists/K+ sparing diuretics
(spironolactone and eplerenone), ACEi, ARBs, NSAIDs, and potassium
supplements
- ECG Signs:
Tall, tented T waves
