Day 2 - Delirium

Diagnosed if patient has:

Inattention with acute onset and fluctuating course and disorganized thinking OR altered LOC.

  • Can present as hypo-, hyperactive or mixed delirium

  • Supportive features include sleep-wake cycle disturbance, hallucinations, delusions, increased or decreased psychomotor activity, inappropriate behavior, and emotional lability

  • Identification of etiology often requires collateral history as patients are unable to provide clear information themselves

Etiology - DIMERS mnemonic

Drugs

  • analgesics

  • anticholinergics

  • sedatives

  • nicotine withdrawal

  • alcohol intoxication or withdrawal

  • street drug intoxication or withdrawal

Infection

  • pneumonia

  • UTI - asymptomatic bacteriuria is hotly debated with respect to its role in pathogenesis of delirium; assess for any symptoms such as dysuria, frequency or suprapubic tenderness and use clinical judgement when deciding whether to treat if asymptomatic

  • cellulitis or skin ulcers

  • abscess

  • meningitis or encephalitis

Metabolic

  • electrolyte abnormalities - sodium, calcium, magnesium

  • hypo/hyperthyroidism

  • hepatic encephalopathy

  • renal encephalopathy

  • B12 deficiency

  • hypoxemia or hypercarbia

Environmental

  • unfamiliar environment

  • lack of visual or hearing aids

Retention

  • Constipation

  • Urinary Retention

  • Pain

Structural

  • stroke

  • ACS or CHF

  • Seizure

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Treatment:

Focus on addressing identifiable causes and using non-pharmacologic interventions. Use of antipsychotics should be avoided as much as possible and limited to situations where patient or staff safety is a concern or patient is in significant distress.

  • re-orient frequently to time and place

  • where possible abort reversal of day/night cycles by having patient out of bed, facing sunlight during the day, lights off, earplugs and quiet room at night

  • minimize sensory deprivation by ensuring patient has their glasses, hearing aids, dentures, etc.

  • frequent visits from familiar family or friends if possible, use of elder life programs where available in hospital

  • encourage mobility, sitting up and out of bed for meals

  • avoid rapid discontinuation of chronic medications - for example, while benzodiazepines are a known risk fact0r for delirium and falls, abrupt discontinuation can also precipitate withdrawal and delirium

    • taper slowly, ideally in the outpatient setting using known guidelines

Medications: Should be reserved for instances where there is concern for patient or staff safety or severe distress. Chemical restraints favoured over physical restraints.

  • Quetiapine: 6.25-25mg po BID

    • agent of choice in patients with Parkinson’s or Lewy Body Dementia

  • Haloperidol: 0.25-1.0mg po BID (breakthrough q4h PRN), 0.25-1.0mg IM, can repeat q30-60min

    • can also be given IV but avoid where possible due to increased risk of arrhythmia and mortality

    • AVOID in patients with Parkinson’s or Lewy Body Dementia

  • Lorazepam: 0.5-1.0mg po

    • do NOT use routinely for delirium

    • indicated only in patients with alcohol or benzodiazepine withdrawal

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