Delirium Management

Delirium Fundamentals - Brain Fog Basics

• Definition: Acute confusional state. Key features: sudden onset, fluctuating course, prominent inattention, and altered level of consciousness or disorganized thinking.
• Types:
  • Hyperactive: Agitated, restless, often hypervigilant.
  • Hypoactive: Lethargic, quiet, withdrawn (frequently missed).
  • Mixed: Fluctuates between hyperactive and hypoactive states.
• Epidemiology: Common in elderly patients, hospitalized individuals (ICU, post-operative).
• Significance: Leads to ↑ morbidity, ↑ mortality, prolonged hospital stay, ↑ costs, and ↑ institutionalization risk.

⭐ Delirium is a medical emergency and a sign of underlying physiological distress.

Causes & Culprits - The Confusion Catalysts

• Predisposing Factors:
  • Age >65 years
  • Pre-existing dementia/cognitive impairment
  • Sensory impairment (vision, hearing)
  • Multiple comorbidities
  • Prior delirium episodes
• Precipitating Factors: 📌 I WATCH DEATH
  • Infection (UTI, pneumonia)
  • Withdrawal (alcohol, benzodiazepines)
  • Acute metabolic (electrolytes, glucose, AKI)
  • Trauma (head injury, post-operative)
  • CNS pathology (stroke, bleed, tumor)
  • Hypoxia (PE, COPD)
  • Deficiencies (B12, thiamine)
  • Endocrinopathies (thyroid, parathyroid)
  • Acute vascular (MI, CVA)
  • Toxins/Drugs (anticholinergics, opioids, sedatives)
  • Heavy metals (rare)
• Pathophysiology (Brief):
  • Neurotransmitter imbalance (Acetylcholine↓, Dopamine↑)
  • Neuroinflammation (Cytokines↑)
  • Impaired network connectivity

⭐ Polypharmacy, especially with anticholinergic drugs, is a major reversible risk factor for delirium in older adults.

Spotting Delirium - Diagnosis Detective

• Hallmarks: Acute onset, fluctuating course, inattention (core), disorganized thinking, altered consciousness.
• Also look for: Cognitive deficits, perceptual issues, psychomotor changes, sleep-wake disruption.

Diagnosis:

• Confusion Assessment Method (CAM):
  • Feature 1: Acute onset & fluctuating course
  • Feature 2: Inattention
  • Feature 3: Disorganized thinking
  • Feature 4: Altered level of consciousness
  • Delirium if: 1 AND 2 AND (3 OR 4)
• 4AT: Rapid tool (score ≥ 4 suggests delirium).
• DSM-5 for formal diagnosis.

⭐ Inattention is the core diagnostic feature of delirium and must be formally assessed.

Delirium vs. Dementia (Key Differentiators):

• Onset: Acute (Delirium) vs. Insidious (Dementia)
• Attention: Impaired early (Delirium) vs. Late (Dementia)

Managing the Maze - Treatment Tactics

Primary Goal: Identify and treat underlying reversible cause(s).

• Non-Pharmacological (First-Line): Cornerstone of management.
  • Environment: Quiet, well-lit room; clocks, calendars for orientation.
  • Support: Family presence, reorientation, early mobilization.
  • Physiological: Sleep hygiene (avoid daytime naps), hydration, nutrition.
  • Sensory: Address impairments (glasses, hearing aids). (e.g., HELP program principles).
• Pharmacological (Severe Agitation/Psychosis Posing Risk):
  • Antipsychotics: Use lowest effective dose, short duration.
    • Haloperidol 0.5-1 mg PO/IM/IV.
    • Risperidone 0.25-0.5 mg PO.
  • ⚠️ Avoid benzodiazepines (except in alcohol/sedative withdrawal delirium).

⭐ Non-pharmacological multicomponent interventions are the cornerstone of delirium management and prevention.

Prevention Power - Keeping Clear Heads

• Identify & manage risk factors; proactive geriatric consult.
• Key: Hospital Elder Life Program (HELP) - orientation, activities, mobilization, sleep, vision/hearing aids, hydration.
• Prognosis: Reversible. Delays: ↑mortality, ↑hospital stay, ↓function, ↑dementia risk.

⭐ The Hospital Elder Life Program (HELP) has been shown to reduce delirium incidence by up to 40% in hospitalized older adults.

High‑Yield Points - ⚡ Biggest Takeaways

• Delirium: acute onset, fluctuating course, with inattention as a core feature.
• Hypoactive delirium is common in elderly, often missed; suspect with acute behavioral change.
• Prevention is key: manage risk factors like dehydration, immobility, sensory impairment.
• Identify and treat precipitating factors: infections, medications, metabolic issues are common.
• Non-pharmacological strategies first: reorientation, promoting sleep, early mobilization.
• Pharmacological: Low-dose antipsychotics (e.g., Haloperidol) for severe agitation; avoid benzodiazepines.
• CAM (Confusion Assessment Method) is a key diagnostic tool for delirium assessment in elderly patients.