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Content # WBA - Delirium # Case - # Delirium - **Causes** - Drugs (polypharmacy/side-effects/withdrawal/intoxication) - Any centrally acting substances - Anticholinergics in particular - Infections - Surgery - Constipation - Urinary retention - Sleep deprivation - **Risk factors** - Brain vulnerabilities: age, dementia and mild-cognitive impairment, long-term alcohol usage - Poor inputs ie. vision and hearing - **Clinical manifestations** - Onset: acute, fluctuating course - Hyperactive: agitated, increased sympathetic activity, psychosis - Hypoactive: increased sleeping, decreased arousal. Poorer prognosis (possibly due to underdetection) - Mixed: fluctuating between above - Other: worse at night, disturbed sleep-wake cycle - **DSM-5 criteria** - Disturbance in attention (focus) and awareness (reduced environmental stimuli) - Acute onset, different to baseline - Additional disturbed cognition (memory, disorientation, language, visuospatial ability or perception) - Cause: must be evidence of a physical cause - Exclusions: not explained by coma or other known neurocognitive disorder - **Tests** - CAM - 4AT - **Management** - Treat the underlying cause - ADEs: review medications for cessation (anything centrally acting, anticholinergics) - Constipation: bowel chart, laxatives - Urinary retention: in/out catheters - Avoid lines where possible - Withdrawal: CIWA, COWS - Manage pain adequately with analgesia - Non-pharmacological and prevention - Optimise sleep (nil evidence for melatonin, avoid BZDs) - Provide orientation eg. windows, family members - Manage sensory inputs eg. hearing aids, vision - Reduce lines and catheters - 1:1 nursing special - Early mobilisation - Lower the bed to reduce falls risk - If hyperactive and at risk of aggression, can use antipsychotics. **WHO CONSENTS?** - Haloperidol 0.5-1mg PO **do these doses actually do anything??????** - Olanzapine 1.25-5mg PO (beware sedation) - Risperidone 0.5-1mg PO (beware EPSE and hypotension) - Quetiapine 25mg PO (particularly in PD or DLB, beware sedation and hypotension) - Escalate to haloperidol 0.5-1mg IM or olanzapine 2.5-5mg IM - eTG says: wait for 30-60 mins for onset. Aim single dose only. Regular courses for 2-3 days max. Cease in case antipsychotics are causing the delirium. Avoid PRN. - Maudsley says: use one drug at a time, small doses regularly compared to large doses less regularly. Maintain at effective dose for 7-10 days after symptoms resolve. - Risperidone and olanzapine have poorer response rates in the elderly - Risperidone 0.5mg BD with PRN (max 4mg/day) - Quetiapine 12.5-50mg BD (max 200mg/day) - Olanzapine 2.5-5mg once daily () - Avoid BZDs due to sedation, respiratory depression and paradoxical excitement unless treating withdrawal. Typically prolongs and worsens delirium. - Pharmacological prophylaxis is contentious - **Differentials** - Dementia - Psychosis - **Complications** - Increases mortality and length of stay - Increases risk of long-term institutional placement - **Prognosis** - Fatal in 37% if untreated. Also progresses to dementia if not treated. - 60% have persistent cognitive impairment - 50% do not recover prior to discharge - 1 year mortality rate in elderly: 35-40% - 3x more likely to develop dementia # Delirium vs Acute Encephalopathy - Delirium is technically the syndrome, encephalopathy the pathology - Acute encephalopathy - Rapidly developing pathobiological process in the brain (within 4 weeks) - Manifests clinically as subsyndromal delirium (ie. does not meet DSM-5 criteria), DSM-5 delirium or coma - However, acute encephalopathy should not be diagnosed by bedside assessment. Note that delirium as per DSM-5 also states that an underlying physiological cause should be present. - Can also have seizures or EPS - Terms such as altered mental status, acute brain failure, acute confusional state should not be used * Ref: https://doi.org/10.1007%2Fs00134-019-05907-4

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