Delirium presents with fluctuating attention.There may be obvious confusion or simply altered levels of consciousness or both. Patients may be aroused and agitated or quiet and withdrawn.
Families find this one of the most distressing symptoms to manage at home.
Delirium is often reversible. However if it presents in the final days of life it may be a multi-factorial terminal delirium/agitation and you must consider if reversal is appropriate at this stage of life.
Red flags
Urgent reversible causes such as sepsis, hypoglycaemia, opioid toxicity and hypercalcaemia must be considered. Alcohol withdrawal is also often forgotten.
Key clinical features to assess in the community
- Assessment of consciousness and mental state
- Underlying diagnosis as this may help identify the cause
- Medication review - opioids and steroids commonly cause delirium
- Physical examination - Temperature/blood pressure/pulse/oxygen saturations. Signs of infection. Check for constipation, urinary retention. Urinalysis and blood glucose.
- Urgent blood tests for a metabolic cause (FBC, U&E, LFT, TFTs, calcium)
- Collateral history is important (depression and dementia are differential diagnoses)
- Review environmental factors contributing to disorientation (e.g. absence of usual hearing/visual aids, noise levels, lighting, access to a clock, disruption of sleep, multiple carer or venue changes)
An initial approach to treatment
- Stop or reduce dose of offending drugs
- Haloperidol 500 micrograms to 3mg oral or subcutaneous (SC) once daily (start with low oral dose) if required to calm the agitated patient (if they are a risk to self) whilst trying to identify a reversible cause. Repeat after 2 hours, if necessary
- Maintain hydration, oral nutrition and mobility if possible
- Consider simple interventions such as 1-1 care if possible from staff or family, a calmer environment, lighting, familiar surroundings or objects
- Consider more specific treatments according to cause - see table below
- A tool for the identification of delirium may help Confusion Assessment Method (CAM)
Key Points
- Do contact the local specialist palliative care team for more specific advice
- Lower starting doses of sedatives in frail elderly
- Sedation is often more difficult to achieve if there is a history of alcohol or substance misuse
- Anti-psychotic medicines are usually more helpful than benzodiazepines
- Levomepromazine is a more sedative anti-psychotic than haloperidol
- Try non-drug methods to relieve agitation first
Specific treatments according to cause (may be multifactorial)
|
Cause |
Initial approach to treatment |
| Drugs (including opioids, anticholinergics, corticosteroids, benzodiazepines, antidepressants, sedatives) |
Reduce the dose or stop offending drug of safe to do so |
| Opioid toxicity (myoclonic jerks, slow breathing, recent dose increase) | If this is suspected, consider reducing the opioid by 30-50% or an opioid switch |
| Drug withdrawal (alcohol, benzodiazepines, antidepressants, nicotine, opioids) | May need sedation if very agitated Nicotine patches can help |
| Dehydration (recent vomiting or diarrhoea, reduced swallowing) | Stop diuretics. May need admission depending on severity and ability to rehydrate orally |
| Physical causes of discomfort including including pain, nausea, constipation, urinary retention, itching due to opioids or organ failure |
|
| Metabolic causes(hypoxia, hypercalcaemia, renal and liver failure, hypoglycaemia) | Reverse if appropriate - may need admission |
| Infection | According to cause |
| Hypoxia (or CO2 retention in COPD) | Oxygen may help (or may be too high in cases of COPD) |
| Cerebral tumour | Dexamethasone |
| Spiritual and psychological distress |
Calm reassurance. Exploration of 'unfinished business'. Music may help. Faith input if relevant. |