 Mr Micheal Reilly  57 year old previously well car salesman  Fall from ladder, admitted with fractured femur  Day 3 post op: agitated, visual hallucinations, odd sensation, describes “ants crawling on skin”, generalised anxiety  Behaviour rapidly fluctuates in hours: danger of falling from bed, verbal + physical aggressiveness, requires sedation.

 Sweaty, tachycardic, mildly febrile, hypertensive  Irregular jerky limb movements  “plucks” at skin and bedclothes  Chest auscultation: bronchial breath sounds at right base  Short term memory loss  Biochem: low Hb, rasied WCC, elevated LFT, low Na and K  ABGs: low O2 and CO2 = resp alkalosis  CXR: right basal consolidation

 Under stress at work (car salesman)  Drinking 1 bottle of scotch every 2-3 days as well as a “few beers” at lunchtime

 Many definitions: awareness, subjective experience, wakefullness  Four entities must coexist: PERCEPTION, MEMORY, EMOTION, ORIENTATION IN SPACE AND TIME  Medically: assessed by observing the patient’s alertness and responsiveness – GCS used  Glascow Coma Scale: reliable obejctive way to record patient’s conscious state › Best Motor Response = 1-6 › Best Verbal Response = 1-5 › Eye Opening = 1-4 Score from 3-15 by adding three areas.

20% elderly patients on wards have some form of delirium. 8 signs to look for: Disordered thinking: slow, irrational, jumbled Euphoric: fearful, depressed, angry Language impaired: repetitive/reduced speech Illusions/delusions/hallucinations: tactile or visual Reversal of sleep/wake cycle: drowsy by day Inattention: shifting attention, poor focus Unaware/disorientated: doesn’t know name/place Memory deficits: short term *note that it normally fluctuates over course of day

 Systemic infection – commonly pneumonia, UTI, wounds etc  Intracranial Infection – encephalitis, meningitis  Drugs – opiates, sedatives, recreational  Alcohol withdrawal – 2-5 days post admission  Metabolic – ureamia, hypoglyceamia, liver failure, malnutrition  Hypoxia – resp of cardiac function  Vascular – stroke, AMI  Head injury – increased ICP, space-occupying lesions  Epilepsy  Nutritional – B12, thiamine or nicotinic acid def.

 Extremes of age – developing or deteriorating brain  Damaged brain – head injury, dementia, previous stroke, alcoholic brain damage  Unfamiliar environment – hospital admission  Sleep deprivation  Immobilisation

 Anxiety if patient is really agitated  Primary mental illness (eg schizophrenia) – particularly if delusions or hallucinations. But be wary that this is very rare.  If auditory hallucinations – psychosis

 FBC - infection  U+E - ureamia  LFTs – alcoholic withdrawal, liver failure  Blood Glucose - hypoglyceamia  ABG’s – hypoxia  Septic Screen (urine dipstick, CXR, blood cultures) - infection  ECG – cardiac failure  CT/MRI – further testing

 Treat underlying condition if known!!  Reduce temperature, rehydrate, review drug therapy, prevent accidents, relocate to single quiet room  Can use music, muscle relaxation and massage to reduce agitation  Encourage family to visit  Try and use same nursing staff to minimise confusion

 Try and minimise, but if needed can use antipsychotics such as: › Haloperidol › Chlorpromazine Best to administer PO but can give IM if necessary.

 Important to reassure family that delirium may persist for several weeks beyond the duration of the illness.  Prognosis dependant on the causative disease and underlying state of the brain.  25% of elderly patients with delirium will have an underlying dementia.  15% will not survive their underlying illness.  40% will be institutionalised within 6 months.