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