Delirium

Delirium is an acute, fluctuating disturbance of consciousness and cognition that is common in the emergency department (ED), particularly among older adults. It is a medical emergency that requires prompt recognition and management to prevent further complications. As a junior doctor in emergency medicine, understanding the causes, assessment, and management of delirium is crucial for effective patient care.

Understanding Delirium

Delirium is characterized by:

• Acute Onset: Symptoms develop over hours to days.

• Fluctuating Course: Symptoms may come and go throughout the day.

• Disturbance in Attention and Awareness: Patients may be easily distracted or unable to focus.

• Cognitive Dysfunction: Including memory impairment, disorientation, or language disturbances.

Delirium can be hyperactive (agitation), hypoactive (lethargy), or mixed.

Common Causes of Delirium

Delirium is often multifactorial and can result from various underlying conditions:

Infections

• Urinary tract infections, pneumonia, or sepsis are common infectious causes, especially in the elderly.

Metabolic and Electrolyte Imbalances

• Hypoglycemia, hypercalcemia, hyponatremia, or dehydration can lead to delirium.

Medications

• Polypharmacy and adverse drug reactions, particularly with anticholinergics, benzodiazepines, or opioids.

Substance Withdrawal

• Alcohol or benzodiazepine withdrawal can precipitate delirium.

Neurological Disorders

• Stroke, head injury, or seizures can cause acute cognitive changes.

Environmental Factors

• Sensory deprivation or overstimulation, sleep deprivation, or unfamiliar surroundings.

Assessment of Delirium

History Taking

A thorough history is essential to identify potential causes:

• Onset and duration of symptoms

• Recent changes in medications or substance use

• History of chronic illnesses or recent infections

• Baseline cognitive function and any recent changes

Physical Examination

The physical examination should focus on identifying signs that may indicate specific causes:

• Vital signs: Check for fever, hypoxia, or hypotension.

• Neurological examination: Assess for focal deficits or signs of stroke.

• General examination: Look for signs of infection or dehydration.

Diagnostic Workup

Depending on clinical suspicion from history and examination, the following tests may be considered:

• Blood Tests: Complete blood count (CBC), electrolytes, renal function tests, liver function tests, glucose levels.

• Urinalysis: To check for urinary tract infections.

• Imaging: CT scan of the head if neurological causes are suspected.

• Electrocardiogram (ECG): To rule out cardiac causes if indicated.

Management Strategies

Management of delirium in the ED focuses on addressing underlying causes and providing supportive care:

1. Identify and Treat Underlying Causes:

   • Initiate appropriate antibiotics for infections.

   • Correct metabolic imbalances such as electrolyte disturbances or hypoglycemia.

   • Review medications and discontinue any non-essential drugs contributing to delirium.

2. Supportive Care:

   • Ensure a safe environment to prevent falls or injuries.

   • Reorient the patient frequently using clocks, calendars, and familiar objects.

   • Optimize sensory input by ensuring adequate lighting and providing glasses/hearing aids if needed.

3. Pharmacological Management:

   • Use antipsychotics like haloperidol cautiously for severe agitation that poses a risk to the patient or staff. Avoid benzodiazepines unless treating alcohol withdrawal.

4. Monitoring and Follow-up:

   • Continuous monitoring for improvement with interventions.

   • Referral to geriatrics or psychiatry for further evaluation if needed.

Challenges and Considerations

Delirium can be challenging due to its multifactorial nature and potential overlap with other cognitive disorders like dementia. Early recognition and intervention are crucial to prevent complications such as prolonged hospital stays or increased mortality. It is important to involve family members in care discussions to understand baseline cognitive function and recent changes.

By taking a systematic approach to the assessment and management of delirium, you can effectively address this condition in the emergency setting while ensuring appropriate follow-up care.