Question 24

College answer

Not available.

Discussion

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
  • Hypertension
  • Alcoholism
  • 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