21st November 2023

Delirium

Though not considered a ‘hot topic’ for the exam, delirium is a frequently seen condition in hospitalised patients.

The following should be considered when suspecting delirium:

1. Age >65 years.
2. Cognitive impairment (past or present), including dementia.
3. Any infectious or inflammatory process (UTI / sepsis/pneumonia).

Symptoms of delirium could include fluctuating cognitive functions such as confusion and poor attention, abnormal perception, agitation, restlessness, sleep disturbance and difficult social behaviour. Hypoactive delirium may include withdrawal, slow responses, reduced mobility and worsened concentration.

The 4AT score can be used to aid in a diagnosis. (Includes alertness, orientation, attention and acute change / fluctuating course). A score of 4 or above is suggestive of a possibility of delirium +/- cognitive impairment.

The management of delirium includes treating the underlying cause, ensuring clear and effective communication, preventing prolonged immobility, addressing pain, addressing polypharmacy, ensuring good hydration and nutrition, managing sensory impairment, and encouraging good sleep hygiene. Verbal de-escalation should be tried before pharmacological agents. If these fail, short-term haloperidol (usually for a week or less) can be given at a low dose and with slow titration.

In case of prolonged delirium, it is always important to rule out dementia and re-evaluate for other underlying causes.

References

• National Institute for Health and Care Excellence (2010). Overview | Delirium: prevention, diagnosis and management | Guidance | NICE. Available online at: https://www.nice.org.uk/guidance/CG103. [Accessed April 2023]