Question 12

College answer

a) Definition: 
The acute onset of a disturbance of consciousness with inattention, changes in cognition and/or perception, that fluctuates over time, occurs as a consequence of a general medical condition and is not better accounted for by a pre-existing, established or evolving dementia. 

b) Causes / Predisposing factors:

• Age >80
• Pre-existing cognitive impairment
• Severity of illness
• Visual impairment
• Dehydration
• Infection/Fever/Hypothermia
• Hypoxia
• Drugs/Polypharmacy o Esp Psychoactive drugs o Anticholinergics,  o Narcotics o Steroids
• Drug withdrawal  o Etoh, Benzos, SSRI
• Metabolic shifts- [Na], renal failure, BSL, Wernickes
• Cardiorespiratory disease
• Sensory deprivation, overstimulation
• Trauma/Post op o Esp – Cardiac sx, Cataract sx, Orthopedics and TURP   

 c) Assessment:

• DSM V
• CAM, CAM ICU
• Memorial delirium assessment scale

d) Treatment

• High-level supportive care 
• Sleep hygiene
• Hydration
• nutrition- thiamine
• Early mobilization
• Avoid physical restraints
• Visual and hearing aids
• Minimize staff changes and utilize family members
• Frequent reorientation
• Do not directly engage or oppose hallucinations/ paranoid behaviours
• Treat underlying cause and precipitant
• Treat psychotic phenomenology
• Haloperidol
•  Risperidone
• Olanzapine
• Dexmetomidine 

Additional Examiners Comments
In general, well answered.

Discussion

This question closely resembles Question 29 from the second paper of 2009. It also features a positive comment from the examiners, which is unprecedented.

a) Definition of delirium (the DSM V definition)

• Disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and awareness.
• Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better accounted for by a preexisting, established, or evolving dementia.
• The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.
• There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.

b) Risk factors:

c) Management of delirium

Non-pharmacological:

• Good analgesia
• Clear and firm communication with the patient
• Frequent re-orientation
• Family presence
• Low-noise environment
• Restoration of hearing aids and spectacles
• Avoidance of sleep disturbance, promotion of normal sleep–wake cycle.
• Avoidance of physical restraints
• Early removal of IV lines and IDC
• Early mobilisation
• Adequate hydration
• Adequate (oral) nutrition
• Use of thiamine

Pharmacological:

• Dexmedetomidine
• Atypical antipsychotics
• Classical antipsychotics
• Benzodiazepines (if withdrawing from alcohol or benzodiazepines)

Oh's Intensive Care manual: Chapter 49   (pp. 549) Disorders  of  consciousness  by Balasubramanian  Venkatesh

Girard, Timothy D., Pratik P. Pandharipande, and E. Wesley Ely. "Delirium in the intensive care unit." Critical Care 12.Suppl 3 (2008): S3.

Barr, Juliana, et al. "Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit." Critical care medicine 41.1 (2013): 263-306.

Ouimet, Sébastien, et al. "Incidence, risk factors and consequences of ICU delirium." Intensive care medicine 33.1 (2007): 66-73.

Van Rompaey, Bart, et al. "Risk factors for intensive care delirium: a systematic review." Intensive and Critical Care Nursing 24.2 (2008): 98-107.

Schweickert, William D., et al. "Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial."Lancet (London, England) 373.9678 (2009): 1874-1882.

Inouye, Sharon K., et al. "A multicomponent intervention to prevent delirium in hospitalized older patients." New England journal of medicine 340.9 (1999): 669-676.