delirium

see also:

• neurology
• RANZCP: Practice Guideline 10, 2009, Antipsychotic medications as a treatment of behavioural and psychological symptoms in dementia (pdf)
• Australian and New Zealand Society for Geriatric Medicine. Position Statement 13. Delirium in Older People. Revised 2012. (pdf)

• delirium is common in elderly hospital inpatients and is associated with increased morbidity and mortality
• early recognition, investigation and management with appropriate inpatient team care is essential to good outcomes by minimising functional and cognitive decline, pressure ulcers and preventing falls.
• it should be differentiated from a primary psychiatric diagnosis such as a psychosis, or from drug or alcohol related withdrawal states.
• it has been proposed that glymphatic dysfunction is the central cause of delirium¹⁾

• the diagnosis of delirium generally requires a present and abnormal rating for criteria (1) AND (2) AND EITHER (3 or 4) of the CAM confusion assessment test for diagnosis of delirium
• Mental state - delirium vs dementia vs psychosis

• ensure there is no immediately manageable cause for acute confusion such as:
  • hypoxia
  • hypotension
  • hypoglycaemia
  • stroke (CVA)
  • pain such as from acute urinary retention
  • sepsis / septicaemia
  • iatrogenic from medication administration
  • thyroid storm

• CAM confusion assessment test for diagnosis of delirium
• Modified Mini-Cog Test or Mini-Mental State Examination

• standard minimal investigations generally include:
  • radiology based on clinical indications:
    • CXR to exclude pneumonia
    • consider AXR to exclude bowel obstruction or sigmoid volvulus
    • CT brain (non-contrast) if focal neurology, history of a fall, or on anticoagulants
    • CT brain with contrast if PH of a neoplasia / cancer / tumours
  • lab tests:
    • FBE, U&E, LFT, CRP, Ca, PO4, TSH
    • blood cultures if suspect sepsis / septicaemia
  • ECG
  • FWT urine and if positive for nitrites or leuks then send for MSU m/c/s and consider commencing IV antibiotics for presumed urosepsis

• pillow under legs to keep heels from contact
• avoid routine IDC insertion
• bladder scan after each void + minimum once per nursing shift to detect acute urinary retention and Mx accordingly (eg. consider in/out catheter but if needed more than twice then insert IDC)
• early referral to Aged Care inpatient team if aged > 65 years or with known dementia and not likely to be a primary psychiatric diagnosis (otherwise refer to Aged Persons Mental Health Unit)

• see:
  • managing violence or the aggressive patient in the ED
  • Behavioural and Psychological Symptoms of Dementia (BPSD)