Delirium: Assessment and Management

Delirium: Core Concepts - Brain Fog Alert

• Definition: Acute confusional state; fluctuating course. Key: impaired attention (cannot focus), reduced awareness, cognitive disturbances (memory loss, disorientation).
• Epidemiology: Common in elderly, hospitalized patients (ICU, post-op). Affects 10-30% of general medical inpatients; higher in vulnerable groups.
• Significance: Leads to ↑ morbidity & mortality, prolonged hospital stays, ↑ healthcare costs, and significant patient/family distress.

⭐ Delirium is a medical emergency and a significant predictor of poor outcomes in hospitalized older adults.

Delirium: Etiology & Risks - The Usual Suspects

• Multifactorial Etiology: Interaction of predisposing & precipitating factors.
• Common Precipitating Factors:
  • Systemic infections (UTI, pneumonia)
  • Medications (anticholinergics, benzodiazepines, opioids, polypharmacy)
  • Metabolic disturbances (electrolytes, hypoxia, hypoglycemia, dehydration)
  • CNS disorders (stroke, trauma)
  • Withdrawal (alcohol, benzodiazepines)
  • Major surgery, uncontrolled pain
• Pathophysiology:
  • Neurotransmitter imbalance: ↓Acetylcholine, ↑Dopamine
  • Neuroinflammation
  • Stress response
• 📌 Mnemonic for Causes: 'I WATCH DEATH'
  • Infection
  • Withdrawal
  • Acute metabolic
  • Trauma
  • CNS pathology
  • Hypoxia
  • Deficiencies
  • Endocrinopathies
  • Acute vascular
  • Toxins/drugs
  • Heavy metals

⭐ Polypharmacy, particularly with drugs having anticholinergic properties, is a major modifiable risk factor for delirium in elderly patients.

Delirium: Clinical Picture & Diagnosis - Confusion Unmasked

• Key Features:
  • Acute onset (hours-days), fluctuating course (sundowning).
  • Core: ↓Attention (focus, sustain, shift), ↓Awareness (disorientation), Cognitive deficits (memory, language, visuospatial, perception: illusions/hallucinations).
  • Additional: Sleep-wake cycle disturbance, psychomotor (hyper/hypo/mixed), emotional lability.
• Diagnosis (DSM-5):
  • Assessment Tools:
    • 📌 CAM (Confusion Assessment Method): Requires (Feature 1 AND Feature 2) AND (Feature 3 OR Feature 4)
      • Feature 1: Acute onset & fluctuating course
      • Feature 2: Inattention
      • Feature 3: Disorganized thinking
      • Feature 4: Altered level of consciousness
    • 4AT score.
• Differentiation: Delirium vs. Dementia vs. Depression

  Feature	Delirium	Dementia	Depression (Pseudo)
  Onset	Acute	Insidious	Subacute
  Course	Fluctuating	Progressive	Diurnal variation
  Attention	Impaired early, fluctuates	Impaired late	Often intact
  Consciousness	Altered, fluctuates	Clear until late	Clear

⭐ Hypoactive delirium: commoner, often missed, worse prognosis.

Delirium: Management & Prevention - Calming the Chaos

• Core Principle: Multicomponent approach.
• 1. Identify & Treat Underlying Cause(s): THE MOST CRITICAL STEP.
• 2. Supportive Care (Non-Pharmacological):
  • Frequent reorientation, adequate lighting, noise reduction.
  • Family presence, encourage mobility, ensure hydration/nutrition.
  • Address sensory impairments (glasses, hearing aids).
  • Maintain sleep-wake cycle.
• 3. Pharmacological Rx (Severe agitation/psychosis, if non-pharm fails):
  • Use lowest effective dose, shortest duration.
  • Antipsychotics:
    • Haloperidol: 0.5-1 mg PO/IM/IV.
    • Risperidone: 0.25-0.5 mg PO.
  • ⚠️ Avoid benzodiazepines (paradoxical agitation, worsen delirium)
    • Exception: Alcohol/sedative withdrawal.
• 4. Prevention:
  • Proactive multicomponent interventions (e.g., HELP program) targeting risk factors.

⭐ Non-pharmacological, multicomponent interventions are the cornerstone of delirium prevention and management; antipsychotics should be used judiciously and for the shortest possible duration.

High‑Yield Points - ⚡ Biggest Takeaways

• Acute onset and fluctuating course are hallmark features of delirium.
• Inattention is a core diagnostic criterion (e.g., digit span, serial 7s).
• Always search for and treat the underlying medical cause.
• EEG typically shows generalized slowing of background activity.
• Management: treat underlying cause, supportive care, low-dose haloperidol for severe agitation.
• Avoid benzodiazepines, except in alcohol/sedative withdrawal delirium.
• Prevention includes reorientation, mobilization, and avoiding polypharmacy.