a) Define delirium. (20% marks)
b) Outline your approach to the prevention of delirium in patients in your ICU. (80% marks)
This question is the repeat of a repeat of a repeat, and is an absolute gift. The weary exam candidate should be able to relax, letting their pen produce a muscle-memory automatic answer while their mind wanders away to a less depressing place.
a) Definition of delirium (the DSM V definition)
- Disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and awareness.
- Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better accounted for by a preexisting, established, or evolving dementia.
- The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.
- There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.
b) Prevention of delirium:
- Identification of at-risk patients
- Pre-existing dementia
- High severity of illness at admission
- Control preventable risk factors:
- Minimise the use/duration of urinary catheters
- Minimise the use of restraints
- Decrease the use of opiates (especially morphine)
- Minimise the use of benzodiazepines (restrict to those who are withdrawing from drugs/alcohol)
- Rationalise polypharmacy
- Where possible, cease or reduce the dose of anticholinergic drugs
- Decrease deliriogenic stimuli of critical care environment:
- Is deliriogenic even a word?
- Encourage mobility: early mobilisation is the most evidence-supported intervention to prevent delirium (
- Minimise intrusive care during sleep, reducing sleep deprivation
- Encourage normal sleep-wake diurnal cycle, sun exposure, make use of rooms with outward-facing windows for delirium-prone patients
- Involve the relatives to calm the patient
- Keep noise to a minimum (eg. silence internal room alarms, turn off loud devices such as the suction catheter)
- Manage pain aggressively
- Prevent constipation proactively
- Watch electrolytes carefully (hypo/hypernatremia, hypo/hypercalcemia, uraemia, etc)
- Give them back their hearing aids and spectacles as soon as practical
- I they are intubated, minimise their sedation doses
- Treat underlying condition:
- Hypoxia, hypercapnia, hypotension - obviously the reason for the ICU admission