Delirium Prevention and Management

Delirium: Definition & Risks - Confusion Code Red

• Definition (DSM-5/ICD): Acute onset, fluctuating course, inattention, altered consciousness, cognitive disturbance (memory, orientation).
• Epidemiology: Common in hospitalized elderly (10-30%), ICU patients (up to 80%).
• Risk Factors:
  • Predisposing: ↑Age, dementia, sensory impairment, prior delirium.
  • Precipitating: Polypharmacy, infection, surgery, dehydration, restraints.
  • 📌 DELIRIUMS Mnemonic: Drugs, Electrolyte imbalance, Lack of drugs (withdrawal), Infection, Reduced sensory input, Intracranial, Urinary retention/fecal impaction, Myocardial/pulmonary, Sleep deprivation.

⭐ Delirium is a medical emergency; failure to recognize it is associated with ↑morbidity & mortality.

Delirium: Causes & Pathophys - Brain Fog Breakdown

• Pathophysiology: Key mechanisms:
  • Neurotransmitter imbalance: ↓Acetylcholine (cholinergic failure), ↑Dopamine.
  • Inflammation: Systemic inflammation impacts brain (↑Cytokines).
  • Stress response: ↑Cortisol, HPA axis dysregulation.
• Common Etiologies: 📌 I WATCH DEATH (Infection, Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia, Deficiencies, Endocrinopathies, Acute vascular, Toxins/drugs, Heavy metals).
• High-Risk Drugs: Anticholinergics, Benzodiazepines, Opioids, Sedative-hypnotics.

⭐ The most common precipitating factor for delirium in elderly hospitalized patients is infection (e.g., UTI, pneumonia).

Delirium: Diagnosis & Features - Spotting Mind Mazes

• Core Features: Acute onset & fluctuating course, Inattention (hallmark), Disorganized thinking (rambling speech), Altered Level of Consciousness (LOC) (not coma).
• Types:
  • Hyperactive: Agitated, restless, hallucinations.
  • Hypoactive: Lethargic, withdrawn, slow speech (⚠️ often missed, worse prognosis).
  • Mixed: Fluctuates between hyper/hypo.
• Diagnosis: Confusion Assessment Method (CAM). Requires (Feature 1 AND 2) AND (Feature 3 OR 4).

- Features: **1.** Acute onset/fluctuating. **2.** Inattention. **3.** Disorganized thinking. **4.** Altered LOC.

• DDx: Dementia (insidious, LOC intact early), Depression (mood primary), Psychosis (thought primary).

⭐ Inattention is the cardinal and most sensitive feature for diagnosing delirium using CAM.

Delirium: Prevention Tactics - Clarity Keepers

• Prioritize non-pharmacological, multicomponent interventions for at-risk patients.
• 📌 HELP (Hospital Elder Life Program) model:
  • Cognitive: Reorientation, therapeutic activities.
  • Sleep: Hygiene, minimize disruptions, noise reduction.
  • Mobility: Early ambulation, range-of-motion.
  • Sensory: Eyeglasses and hearing aids.
  • Intake: Optimize hydration and nutrition.
• Medication Review: Minimize/stop high-risk psychoactive drugs (benzodiazepines, anticholinergics).
• Environment: Calm, safe. Clocks, calendars, familiar items. Good lighting, clear signs.

⭐ Non-pharmacological multicomponent strategies reduce delirium incidence by 30-40% in hospitalized older adults.

Delirium: Management Steps - Calm Command

• Identify & Treat Underlying Cause(s): Paramount.
• Supportive Care (Non-Pharmacological First-Line):
  • Reorientation, calm environment, consistent caregivers.
  • Family presence, familiar objects, sensory aids (glasses, hearing aids).
  • Maintain sleep-wake cycle (natural light, ↓nocturnal noise, sleep hygiene).
  • Ensure safety (mobilize with aid, prevent falls, clear pathways).
• Pharmacological Management (IF severe agitation/psychosis posing risk to self/others):
  • Start low, go slow. Aim for shortest duration.
  • Antipsychotics:
    • Haloperidol 0.5-1 mg PO/IM/IV (monitor QTc).
    • Risperidone 0.25-0.5 mg PO.
    • Olanzapine 2.5-5 mg PO/IM.
  • ⚠️ AVOID Benzodiazepines (can worsen delirium).

    ⭐ Exception: Benzodiazepines (e.g., Lorazepam) are first-line for delirium due to alcohol or sedative withdrawal.

• Physical Restraints: Last resort, minimal duration, regular review & documentation.

High‑Yield Points - ⚡ Biggest Takeaways

• Delirium: Acute onset, fluctuating course, and inattention are key features.
• Major risk factors: Advanced age, pre-existing dementia, polypharmacy, infection, and surgery.
• Prevention is crucial: Emphasize reorientation, early mobilization, sleep hygiene, and hydration.
• CAM (Confusion Assessment Method) is a standard diagnostic tool.
• Management: Treat the underlying cause, provide supportive care, and implement environmental modifications.
• Antipsychotics (e.g., haloperidol) for severe agitation; use low dose, short duration.
• Avoid benzodiazepines unless delirium is due to alcohol or sedative withdrawal.