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Common delirium exam questions for medical finals, OSCEs and MRCP PACES

Click on the plus symbols to see the answers to each of these questions about delirium

Question 1.

What is delirium?

  • An acute disturbance of the mind, with features including (but not limited to):
    • Memory impairment
    • Disorganised thinking
    • Hallucinations (particularly visual)
    • Personality changes
    • Changes in sleep pattern
  • These changes often fluctuate in severity, can be rapid in onset, and are usually reversible

 

Question 2.

What are the basic types of delirium?

  • Hyperactive delirium
    • Increased agitation (e.g. fiddling at bed sheets, wandering on the ward, calling out)
    • Hallucinations (visual or auditory)
    • Altered personality (e.g. more aggressive)
    • Altered sleep pattern (e.g. daytime sleeping and night-team waking)
    • New or worsening confusion
  • Hypoactive delirium
    • Increasingly withdrawn and uncommunicative
    • Worsening mood and depression-like symptoms
    • Worsening oral intake and failure to self-initiate activities of daily care
    • Worsening mobility
    • Poor concentration and poor persistence
      • E.g. giving up on tasks quickly – can relate back to poor oral intake
    • In the extreme cases, can lead to catatonic states

 

Question 3.

What are risk factors for delirium?

  • Infection
  • Pain
  • Constipation
  • Urinary retention
  • Drugs
    • E.g. side-effects of analgesics such as opiates or neuroleptics
    • E.g. sudden withdrawal of alcohol (delirium tremens)
  • Diseases causing cerebral irritation
    • E.g. encephalitis/meningitis
    • E.g. post-ictal in an epileptic patient
  • Unfamiliar places/surroundings
    • E.g. hospitals
  • Poor lighting/lack of natural light
    • E.g. hospitals
  • Abnormal electrolyte/plasma concentrations
    • E.g. uraemia, hyponatraemia, hypercalcaemia
  • Surgical interventions
    • Potentially secondary to post-op complications such as pain/infection as above
    • Increased risk of delirium secondary to general anaesthetic – ongoing research into the effects of induction agents on the brain in mouse models
  • Patients with terminal conditions

 

Question 4.

What are the non-medical management strategies for delirium?

  • Reversing the underlying cause of the delirium is key to the treatment of delirium
  • Ensure all possible causes of delirium have been reviewed and appropriately treated
    • In view of the wide range of possible causes, it is beyond the scope of this section to discuss the treatment of each of them in detail – ensure each has been considered, and if a potential cause, treat appropriately
  • To treat the symptoms themselves, try to not resorting to pharmacological therapies straight away as they can make the symptoms worse
    • Re-orientate the patient to the time, place, person whenever you interact with them
    • Leave a brief summary of where they are and what they are being treated for in front of them, to act as a regular reminder
    • If a particular patient is very agitated, and if staffing allows, 1-1 nursing can provide more support to a patient that pharmacological intervention can ever manage
    • Try to ensure familiar faces are nearby to reassure the patient (e.g. family members, photos, healthcare professionals who have cared for the patient regularly)

Question 5.

If this fails, what can be done next?

  • If despite treatment of the underlying cause, or if whilst the delirium is resolving and despite non-pharmacological treatments as suggested above, a patient remains acutely agitated and a risk to themselves or others, they may need further intervention
    • Short-courses of antipsychotics
      • Haloperidol (0.5mg to 1.5mg PO or SC – ideally on a OD dosing. Only IM if absolutely necessary)
      • Olanzapine (2.5mg po 5mg PO or SC – up to 2-hourly, max 3 doses/24h)
    • If at all possible, benzodiazepines should be avoided
    • The medications above should be reviewed on a regular basis and stopped as soon as possible
    • Caution should be used when using such medications in a patient with a background of pre-existing dementia, in particular Lewy Body dementia, Parkinson’s Disease or Parkinson’s Plus syndromes.  If possible, they should not be used in these patients.
  • In severe hypoactive delirium where oral intake is impaired, artificial methods of supporting their nutritional status may be required such as NG-feeding
  • Deprivation of Liberty Safeguards (DOLS)
    • DOLS may be required in order to safely treat a patient on the ward who – due to their delirium – lacks to capacity to agree to treatment
    • DOLS should ideally be completed in any patient who has any form of limitations to their freedom, which has been done in their best interests
      • E.g. stopping a confused patient from leaving the ward
      • E.g. putting on mittens to prevent them pulling out lines
      • E.g. leaving the side-rails of the bed up to stop them from falling or climbing out
    • Some of these examples may seem extreme, but they are important safeguards for both patients and healthcare professionals to ensure safe and ethical treatment of the acutely delirious patient

 

 Question 6.

What is the Confusion Assessment Method (CAM)?

  • The CAM is a valided method of diagnosing delirium
  • A positive or negative result depends on four criteria:
    • 1. Acute onset and fluctuating course
      • Determined by collateral history or repeated clinic assessment
    • 2. Inattention
      • Counting from 20-1 is a simple (if blunt) test for this
    • 3. Disorganised thinking
    • 4. Altered levels of consciousness
  • The CAM is considered to be positive for the presence of delirium if both features 1 and 2 are present, with at least one of features 3 or 4.

 

Question 7.

What questions are in the AMTS?

  • Age
  • Current time (to the nearest hour)
  • Recall: Ask the patient to remember an address (e.g. 42 West Register Street)
    • Ensure they are able to say it back to you immediately, then check recall at the end of the test
  • Current year
  • Current location (e.g. name of hospital or town)
  • Recognise two people (e.g. relatives, carers, or if none around, the likely profession of easily identified people such as doctor/nurse)
  • Date of birth
  • Years of the first (or second) world war
  • Name of the current monarch (or prime minister)
  • Count sequentially backwards from 20 to 1
    • A score of less than 8 in the AMTS implies the presence of cognitive impairment

 

Question 8.

How do I assess a person’s capacity to make a decision?

  • In order to have capacity, a person must be able to:
    • Understand the information about the decision presented to them
    • Retain this information long enough to make a decision
    • Be able to weigh up the information in order to arrive at their decision
    • Communicate their decision (verbally or non-verbally)
  • If any one of the above points is absent, they are deemed to lack capacity
    • An unwise decision is not the same as a non-capacitous decision
  • Do not make the mistake of being asked to decide if a patient has “capacity” in general
    • Capacity is decision specific
    • E.g. A person’s capacity to decide what they want for breakfast does not equate to them having the capacity to decide if they want to risk-feed in view of their poor swallow, or have a PEG sited

 

Question 9.

What are the Deprivation of Liberty Safeguards (DOLS)?

    • DOLS are a legal set of safeguards to ensure protection for a patient who – for reasons of disturbances to their mental health – lack to capacity to make decisions about their care and treatment and, as such, have their liberty deprived as part of this ongoing care or treatment
    • In particular, the DOLS are designed to ensure:
      • A patient, who has their liberty deprived, has an independent representative to act upon their behalf
      • That the deprivation of their liberty is reviewed on a regular basis
      • That the patient – or their representative as assigned above – has a legal basis on which to challenge the deprivation of liberty through the court of protection
    • It has been noted by some clinicians (perhaps cynically) that DOLS are more about legally protecting healthcare professionals rather than the wellbeing of the patients it was intended for
    • DOLS must deprive a patient’s liberty in the most minimally restrictive way possible
      • The exact details of what this entails is determined on a case-by-case basis during the formal assessment process

 

Question 10.

Why would anyone need a DOLS?

  • An 80-year old suffering from advanced dementia and recurrent falls who, following IM nailing of a fractured neck of femur is now poorly mobile, but wants to be discharged home. Her family and the medical team feel she needs placement to a nursing home
    • If she lacks the capacity to understand that she would be unsafe for a discharge home in view of her inability to care for herself, feed herself etc. one would argue that placement in a nursing home is in her best interests
    • However, a nursing home placement goes against her own (albeit non-capacitous) wishes
    • A DOLS would be required as part of proceeding with arranging a nursing home placement, and for keeping her on the ward whilst this process is completed
  • DOLS also apply to people who are being held under section from the mental health act