Adult Medical Emergency Handbook - Scottish Intensive Care Society

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Chapter 8
ACUTE DETERIORATION IN THE ELDERLY
DELIRIUM
Delirium is a medical emergency and needs prompt
assessment and treatment.
Delirium (‘acute confusional state’) is an acute deterioration in cognition,
often with altered arousal (drowsiness, stupor, or hyperactivity) and
psychotic features (eg. paranoia). The main cognitive deficit in delirium
is ‘inattention’, eg. the patient is distractable, cannot consistently
follow commands, and loses the thread during a conversation.
Delirium is different from dementia, where there is a much slower
decline in cognition and inattention is much less prominent, but the
two conditions commonly co-exist.
Delirium affects 1 in 5 of older patients in hospital. It is important
because it frequently indicates serious illness – NB ‘confusion’ in the
CURB-65 score. The outcome is frequently poor.
CAUSES OF DELIRIUM
• Three main groups:
1. physical and psychological stress: any acute illness, trauma,
surgery, etc.
2. drugs: drugs with anticholinergic activity (eg. amitriptyline,
oxybutinin), opiates, benzodiazepines, steroids; also drug
withdrawal (eg. benzodiazepines, alcohol)
3. metabolic, eg. hyponatraemia, hypercalcaemia, hypoglycaemia
• Note that a higher number of predisposing factors (old age,
baseline cognitive impairment, multiple comorbidities) mean that
an apparently minor insult, eg. a UTI or a change of drugs, can
precipitate delirium.
INITIAL ASSESSMENT
• Delirium should be suspected in any patient with (a) cognitive
impairment and/or altered arousal and (b) evidence that the
altered mental status is of recent onset (hours, days, weeks).
• Therefore, to screen for delirium you need to assess cognition
and arousal, and seek a third party history regarding the patient’s
baseline state.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11
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