see: [Dunn - Altered mental state](x-devonthink-item://B3EEA5EC-E13D-441F-BF70-51B5DE18585E) and [Rosen - Delirium and dementia](x-devonthink-item://75044798-5D97-4808-98FA-2ECBCD8717CE) , [Dunn - Ageing](x-devonthink-item://92393F6C-B226-45A8-B405-8FF60C699DDD)[bear geriatric sedation](bear://x-callback-url/open-note?id=9E5A56AB-8311-482F-AD97-2B40637F765B-94035-00001093D8490E17)
see also: [[Violence in ED#Risk factors for organic cause| occupational violence → risk factors for organic cause]], [[schizophrenia#Drug-induced psychosis vs schizophrena|schiziphrenia vs drug-induced psychosis]]
[[Confusion]], [[Hot and bothered]]
**Definition:** *Delirium* is an acute condition characterized by an altered level of attention and awareness. It develops during a short time, and symptoms tend to fluctuate throughout the day (rosen). global cognitive impairment with clouding of consciousness and fluctuating conscious state (Dunn)
- impaired cognition, visual hallucinations, and confabulation support organic cause for altered behaviour / mental state
- *structured delusions* supports psychosis
- in delirium, delusions are unstructured and vague
**potential precipitants of delirium and ix:**
| precipitant | ix |
| --------------------------------------------- | -------------------------------------- |
| infection | exam, urine for UTI, CXR for pneumonia |
| AMI | 12 lead ECG |
| pain | exam, XR for fracture |
| [[hypoglycaemia\|hypoglycemia]] | BGL |
| [[hyponatremia\|hypo-na]] | UEC |
| polypharm, new med (eg steroids) | med review |
| acute or subacute neurological event (eg SDH) | CTB |
| hypothyroid or [[thyrotoxicosis]] | TFTs |
## Delirium vs dementia vs psychosis
| | delirium | dementia | psychosis |
| ---------------------- | ----------------------------- | ----------------------- | -------------------------------------------------- |
| onset | acute | gradual | variable but usually slow if not drug-induced |
| attention | impaired | normal / attentive | may be inattentive or responding to hallucinations |
| level of consciousness | fluctuates | normal or alert | generally alert |
| orientation | variable | impaired | normal or variable |
| memory | often impaired; confabulation | impaired | |
| hallucinations | present | usually absent | common |
| Delusions | Unstructured or vague | Rare | Structured delusions |
| language | slowed, aphasia | word finding difficulty | pressured |
# 4AT screen
1. alertness
2. abbreviated mental test (disorientation) age/DOB/place/year
3. attention (month backwards, get to 7)
4. acute change or fluctuating course
≥4 possible delirium and/or cognitive impairment; 0-3 possible cognitive impairment
# treatment for geriatric delirium and agitation
see also: [[Violence in ED#Restraint]]
>**TADA** approach: tolerate, anticipate, do not agitate
- non-pharm: verbal de-escilation, calm, lights off. bring family in, food+ drink
- orientation aids: clock, calenders
- encourage safe mobilisation
- minimise room and staffing changes
- address hydration and nutrition
- ensure vision and hearing: glasses and hearing aids available
- staff behaviour: (TADA approach: tolerate, anticipate, do not agitate)
- expeidite movement out of ED
- access to daylight, single room/ quet area, dark at night
- regular toileting
- specialised staff training in geriatrics and delirium recognition
- treat reversible causes eg pain, IDC for urinary retention, hypoglycaemia
- po medication (pick one):
- olanzapine 1.25-2.5 mg as single dose
- haloperidol 0.5mg orally as single dose
- risperidone 0.5mg orally
- if they have **PKD**, use quetiapine 25mg orally
- can consider diazepam 2.5-5mg orally Q30 min (max 30 mg) or lorazepam 0.5-1mg po orally Q30 min (max 3mg) for behavioural disturbance
- onsider physical restraint of pt and staff are at risk to facilitate parenteral chemical restraint
- if need to give IM for delirium:
- haloperidol 0.5 mg IM or olanzapine 2.5 mg IM
- droperidol 5mg IM also an option
- if needing regular Rx; rispiridone 0.25mg BD, olanzapine 2.5mg po, or quetiapine 12.5-25mg po once or twice daily